Provider Demographics
NPI:1245411701
Name:SOUTHERN WEST VIRGINIA PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SOUTHERN WEST VIRGINIA PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:304-855-9500
Mailing Address - Street 1:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-1647
Mailing Address - Country:US
Mailing Address - Phone:304-855-9500
Mailing Address - Fax:304-855-9525
Practice Address - Street 1:6107 CRAWLEY CREEK RD.
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508
Practice Address - Country:US
Practice Address - Phone:304-855-9500
Practice Address - Fax:304-855-9525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302394000Medicaid
WV9333941Medicare PIN