Provider Demographics
NPI:1114042116
Name:SUPERIOR REHAB, LLC
Entity Type:Organization
Organization Name:SUPERIOR REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:419-331-2161
Mailing Address - Street 1:3477 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-3755
Mailing Address - Country:US
Mailing Address - Phone:419-331-2161
Mailing Address - Fax:419-227-7767
Practice Address - Street 1:3477 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3755
Practice Address - Country:US
Practice Address - Phone:419-331-2161
Practice Address - Fax:419-227-7767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000365466OtherGROUP ANTHEM PIN
OH000000365466OtherGROUP ANTHEM PIN
OH000000365466OtherGROUP ANTHEM PIN