Provider Demographics
NPI:1053316182
Name:GREENDALE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:GREENDALE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:IGNASIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-853-4590
Mailing Address - Street 1:280 BOSTON TPKE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-2640
Mailing Address - Country:US
Mailing Address - Phone:508-853-4590
Mailing Address - Fax:949-756-4811
Practice Address - Street 1:280 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2640
Practice Address - Country:US
Practice Address - Phone:508-753-7780
Practice Address - Fax:508-753-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0004259Medicare PIN