Provider Demographics
NPI:1164720587
Name:GENOA CITY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:GENOA CITY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:847-254-1708
Mailing Address - Street 1:5809 ROCKY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-1338
Mailing Address - Country:US
Mailing Address - Phone:847-254-1708
Mailing Address - Fax:423-269-8746
Practice Address - Street 1:313 FREEMAN STREET
Practice Address - Street 2:
Practice Address - City:GENOA CITY
Practice Address - State:WI
Practice Address - Zip Code:53128
Practice Address - Country:US
Practice Address - Phone:262-279-8000
Practice Address - Fax:262-295-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9814-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100015187Medicaid