Provider Demographics
NPI:1407080740
Name:INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Entity Type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY OF GA, LLC
Other - Org Name:BENCHMARK PT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-8923
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1689 OLD PENDERGRASS RD STE 300
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-2716
Practice Address - Country:US
Practice Address - Phone:706-387-0212
Practice Address - Fax:706-387-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X
GA261QM1300X, 261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
116807Medicare Oscar/Certification