1841488897 NPI number — BACK IN THE GAME

Table of content: (NPI 1841488897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841488897 NPI number — BACK IN THE GAME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK IN THE GAME
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:
1841488897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 WILDWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ALBANY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47150-5429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-282-4263
Provider Business Mailing Address Fax Number:
812-288-6441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2940 HOLMANS LN
Provider Second Line Business Practice Location Address:
STE. B
Provider Business Practice Location Address City Name:
JEFFERSONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47130-6911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-282-4263
Provider Business Practice Location Address Fax Number:
812-288-6441
Provider Enumeration Date:
10/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
MADONNA
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
812-282-4263

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  05002013A , 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: 000000230208 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200421930A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA7238 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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