Provider Demographics
NPI:1003075052
Name:PLATINUM PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PLATINUM PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:931-393-2378
Mailing Address - Street 1:1816 N WASHINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-393-2378
Mailing Address - Fax:931-455-9983
Practice Address - Street 1:1816 N WASHINGTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-393-2378
Practice Address - Fax:931-455-9983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT962225100000X
TNOT3437225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4207023OtherBLUE CROSS BLUE SHIELD TENNESSEE
TN3370356Medicaid
TNDQ1710OtherPALMETTO GBA-RAILROAD MEDICARE
TN4207023OtherBLUE CROSS BLUE SHIELD TENNESSEE
TN4207023OtherBLUE CROSS BLUE SHIELD TENNESSEE