Provider Demographics
NPI:1386662823
Name:FIRST MED EAST PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FIRST MED EAST PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WORTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-417-5017
Mailing Address - Street 1:PO BOX 702128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84170-2128
Mailing Address - Country:US
Mailing Address - Phone:801-708-7867
Mailing Address - Fax:801-677-1510
Practice Address - Street 1:1950 FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6894
Practice Address - Country:US
Practice Address - Phone:801-943-1041
Practice Address - Fax:801-943-3461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110326-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057786Medicare PIN