Provider Demographics
NPI:1376546341
Name:NEUROSPORT PHYSICAL THERAPY & REHABILITATION SPECIALIST INC.
Entity Type:Organization
Organization Name:NEUROSPORT PHYSICAL THERAPY & REHABILITATION SPECIALIST INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MORIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-321-0155
Mailing Address - Street 1:1163 JOHNSON FERRY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-2764
Mailing Address - Country:US
Mailing Address - Phone:770-321-0155
Mailing Address - Fax:770-321-8426
Practice Address - Street 1:1163 JOHNSON FERRY RD
Practice Address - Street 2:STE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2764
Practice Address - Country:US
Practice Address - Phone:770-321-0155
Practice Address - Fax:770-321-8426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5093346OtherAETNA PPO, MC
606717OtherAETNA HMO
52266108OtherBCBS OF GEORGIA
GA650016944OtherRAILROAD MEDICARE
GA650016944OtherRAILROAD MEDICARE