1669672242 NPI number — INDY PHYSICAL THERAPY

Table of content: (NPI 1669672242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669672242 NPI number — INDY PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDY PHYSICAL THERAPY
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:
1669672242
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5250 E US HIGHWAY 36
Provider Second Line Business Mailing Address:
STE 420
Provider Business Mailing Address City Name:
AVON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46123-9199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-849-3517
Provider Business Mailing Address Fax Number:
317-849-6397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5250 E US HIGHWAY 36
Provider Second Line Business Practice Location Address:
STE 420
Provider Business Practice Location Address City Name:
AVON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46123-9199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-849-3517
Provider Business Practice Location Address Fax Number:
317-849-6397
Provider Enumeration Date:
07/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANZELLI
Authorized Official First Name:
PETE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/MPT
Authorized Official Telephone Number:
317-849-3517

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  53000103A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000505369 . This is a "ANTHEM/BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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