Provider Demographics
NPI:1346205598
Name:SOUTHSIDE PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:SOUTHSIDE PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABOL
Authorized Official - Middle Name:
Authorized Official - Last Name:DADFARMAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-826-8866
Mailing Address - Street 1:8601 CREEKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9211
Mailing Address - Country:US
Mailing Address - Phone:317-826-8866
Mailing Address - Fax:
Practice Address - Street 1:3440 S POST RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-8301
Practice Address - Country:US
Practice Address - Phone:317-862-2860
Practice Address - Fax:317-862-0928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001800A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN156533Medicare ID - Type Unspecified