Provider Demographics
NPI:1306851282
Name:LIBERTY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LIBERTY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WURSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:401-722-0012
Mailing Address - Street 1:872 SMITHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865
Mailing Address - Country:US
Mailing Address - Phone:401-722-0012
Mailing Address - Fax:401-722-0056
Practice Address - Street 1:872 SMITHFIELD AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865
Practice Address - Country:US
Practice Address - Phone:401-722-0012
Practice Address - Fax:401-722-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2007-11-14
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
6400365OtherUHP