Provider Demographics
NPI:1295837722
Name:GLOUCESTER PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:GLOUCESTER PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAIKUTLO
Authorized Official - Middle Name:B
Authorized Official - Last Name:KEBAETSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PT
Authorized Official - Phone:856-224-0400
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:PAULSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08066-0277
Mailing Address - Country:US
Mailing Address - Phone:856-224-0400
Mailing Address - Fax:856-224-0466
Practice Address - Street 1:541 MANTUA AVE
Practice Address - Street 2:
Practice Address - City:PAULSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08066-1178
Practice Address - Country:US
Practice Address - Phone:856-224-0400
Practice Address - Fax:856-224-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00685900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2410631000OtherAMERIHEALTH IND. ID #
NJ2410669000OtherAMERIHEALTH GROUP ID
NJ090041Medicare PIN
NJ090044T42Medicare ID - Type UnspecifiedRENDERING NUMBER