Provider Demographics
NPI:1033234638
Name:WELLPOINT PHYSICAL THERAPY SERVICES, P.C.
Entity Type:Organization
Organization Name:WELLPOINT PHYSICAL THERAPY SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PHD
Authorized Official - Phone:979-690-1999
Mailing Address - Street 1:PO BOX 11165
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77842-1165
Mailing Address - Country:US
Mailing Address - Phone:979-690-1999
Mailing Address - Fax:979-690-1906
Practice Address - Street 1:4190 STATE HIGHWAY 6 S
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8964
Practice Address - Country:US
Practice Address - Phone:979-690-1999
Practice Address - Fax:979-690-1906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1093607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0057JZOtherBLUE CROSS BLUE SHIELD
TX166736201Medicaid
TX00551VMedicare ID - Type Unspecified