Provider Demographics
NPI:1114272515
Name:OUTBACK PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:OUTBACK PHYSICAL THERAPY, INC.
Other - Org Name:OUTBACK PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:JOTKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:617-718-9300
Mailing Address - Street 1:149A HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-1650
Mailing Address - Country:US
Mailing Address - Phone:617-718-9300
Mailing Address - Fax:617-718-9303
Practice Address - Street 1:149A HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-1650
Practice Address - Country:US
Practice Address - Phone:617-708-9300
Practice Address - Fax:617-718-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001977901Medicare PIN