Provider Demographics
NPI:1164474334
Name:BAY STATE PHYSICAL THERAPY OF RANDOLPH INC
Entity Type:Organization
Organization Name:BAY STATE PHYSICAL THERAPY OF RANDOLPH INC
Other - Org Name:BAY STATE PHYSICAL THERAPY OF RANDOLPH PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINDWER
Authorized Official - Suffix:
Authorized Official - Credentials:DC/PT
Authorized Official - Phone:781-961-3370
Mailing Address - Street 1:703 GRANITE ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-5350
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:703 GRANITE ST STE 300
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-5350
Practice Address - Country:US
Practice Address - Phone:781-961-3370
Practice Address - Fax:781-961-1291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 225100000X
MA225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA689511OtherTUFTS HEALTH PLAN
MA9705601Medicaid
MA626127OtherHARVARD PILGRIM
MA0009411OtherALLWAYS HEALTHCARE (FORMERLY NHP)
MA684486OtherOPTUM/UHC
MAPT0101OtherMEDICARE PIN
MAY61008OtherBLUE CROSS BLUE SHIELD (MA)