Provider Demographics
NPI:1003931288
Name:WYMER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WYMER PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:WYMER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:361-879-0920
Mailing Address - Street 1:4455 S PADRE ISLAND DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-5101
Mailing Address - Country:US
Mailing Address - Phone:361-879-0920
Mailing Address - Fax:361-879-0940
Practice Address - Street 1:4455 S PADRE ISLAND DR
Practice Address - Street 2:SUITE 8
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-5101
Practice Address - Country:US
Practice Address - Phone:361-879-0920
Practice Address - Fax:361-879-0940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1030773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28012OtherBCBS BLUELINK #
TXB0028012OtherBCBS UPIN#
TX659504OtherBCBS PROVIDER #
TX10779438OtherCAQH PROVIDER #
TX1080186-02Medicaid
TX200006701OtherDEPARTMENT OF LABOR #
TX1080186-02Medicaid
TX200006701OtherDEPARTMENT OF LABOR #