Provider Demographics
NPI:1043347735
Name:PHYSIOTHERAPY ASSOCIATES INC
Entity Type:Organization
Organization Name:PHYSIOTHERAPY ASSOCIATES INC
Other - Org Name:PHYSIOTHERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:FLECK
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-467-8705
Mailing Address - Street 1:665 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3941
Mailing Address - Country:US
Mailing Address - Phone:724-465-3496
Mailing Address - Fax:215-413-4682
Practice Address - Street 1:1234 E DUPONT RD
Practice Address - Street 2:#7
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-490-0940
Practice Address - Fax:260-490-5063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100133720WMedicaid
IN000000175000OtherBLUE CROSS BLUE SHEILD
IN100133720WMedicaid