Provider Demographics
NPI:1144450537
Name:INDEPENDENT PHYSICAL THERAPY
Entity type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-7217
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:259 N PETERS RD STE 102
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4926
Practice Address - Country:US
Practice Address - Phone:865-691-8381
Practice Address - Fax:865-691-8574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN03650060Medicaid
TN3156797OtherBCBST
TN3650060Medicare Oscar/Certification