Provider Demographics
NPI:1407291487
Name:WELLBRIDGE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:WELLBRIDGE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADIMIR
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:SHURSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:617-965-8070
Mailing Address - Street 1:48 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6096
Mailing Address - Country:US
Mailing Address - Phone:781-354-5196
Mailing Address - Fax:
Practice Address - Street 1:48 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6096
Practice Address - Country:US
Practice Address - Phone:781-354-5196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110097752AMedicaid