Provider Demographics
NPI:1417393364
Name:INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Entity Type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC
Other - Org Name:BENCHMARK - CARTERSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF CLAIMS
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-7217
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:626 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-3305
Practice Address - Country:US
Practice Address - Phone:770-383-9734
Practice Address - Fax:770-383-9831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4895Medicare UPIN