Provider Demographics
NPI:1417221433
Name:INTEGRA PHYSICAL THERAPY,SC
Entity Type:Organization
Organization Name:INTEGRA PHYSICAL THERAPY,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-351-8482
Mailing Address - Street 1:8677 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2209
Mailing Address - Country:US
Mailing Address - Phone:414-351-8482
Mailing Address - Fax:414-351-8483
Practice Address - Street 1:8677 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:FOX POINT
Practice Address - State:WI
Practice Address - Zip Code:53217-2209
Practice Address - Country:US
Practice Address - Phone:414-351-8482
Practice Address - Fax:414-351-8483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9931261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100024282Medicaid