1073652822 NPI number — ADVANCED PHYSICAL THERAPY AND ORTHOPEDIC REHABILITATION PC

Table of content: (NPI 1073652822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073652822 NPI number — ADVANCED PHYSICAL THERAPY AND ORTHOPEDIC REHABILITATION PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PHYSICAL THERAPY AND ORTHOPEDIC REHABILITATION PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073652822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 E BARNETT RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-8672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-773-7776
Provider Business Mailing Address Fax Number:
541-773-7786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 E BARNETT RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-8672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-773-7776
Provider Business Practice Location Address Fax Number:
541-773-7786
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHIMEK
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
541-773-7776

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT3277 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225200000X , with the licence number: PTA7591 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00117730 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 209044 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3000166 . This is a "GEHA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0007177429 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: DB6155 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: K332601 . This is a "PACIFIC SOURCE" identifier . This identifiers is of the category "OTHER".




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