Provider Demographics
NPI:1225013873
Name:ADAMS, ROY (PT, FMSK)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PT, FMSK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1085
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-3185
Mailing Address - Country:US
Mailing Address - Phone:260-726-6828
Mailing Address - Fax:260-726-2257
Practice Address - Street 1:111 W NORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1153
Practice Address - Country:US
Practice Address - Phone:260-726-6828
Practice Address - Fax:260-726-2257
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN7774225100000X
IN05001458A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000105382OtherANTHEM BLUE CROSS & BLUE SHIELD
IN200154330Medicaid
IN000000105382OtherANTHEM BLUE CROSS & BLUE SHIELD
IN200154330Medicaid