Provider Demographics
NPI:1023028834
Name:CROSSROADS ORTHOPEDIC SUBSPECIALISTS, LLC DBA CROSSROADS PHYSICAL THER
Entity Type:Organization
Organization Name:CROSSROADS ORTHOPEDIC SUBSPECIALISTS, LLC DBA CROSSROADS PHYSICAL THER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-365-6560
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6560
Mailing Address - Fax:
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:SUITE 202
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-447-2193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03419Medicare PIN