Provider Demographics
NPI:1275585341
Name:INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Entity Type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Other - Org Name:BENCHMARK PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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 1:2550 WINDY HILL RD SE STE 208
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8654
Practice Address - Country:US
Practice Address - Phone:770-916-1567
Practice Address - Fax:770-916-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomicsGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACK9205OtherRAILROAD MEDICARE PROVIDER #
GAGRP4895Medicare PIN