Provider Demographics
NPI:1275908246
Name:PHYSICAL REHABILITATION GROUP
Entity Type:Organization
Organization Name:PHYSICAL REHABILITATION GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:803-732-5887
Mailing Address - Street 1:PO BOX 3408
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-4015
Mailing Address - Country:US
Mailing Address - Phone:803-732-5887
Mailing Address - Fax:803-732-5997
Practice Address - Street 1:2608 MAIN ST UNIT A
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3760
Practice Address - Country:US
Practice Address - Phone:803-732-5887
Practice Address - Fax:803-732-5997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICAL REHABILITATION GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-02
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8438Medicare PIN