Provider Demographics
NPI:1467594143
Name:ATLANTIS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ATLANTIS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:YATSKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:617-436-3200
Mailing Address - Street 1:834 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1607
Mailing Address - Country:US
Mailing Address - Phone:617-436-3200
Mailing Address - Fax:617-436-1555
Practice Address - Street 1:15 CHRISTOPHER ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1218
Practice Address - Country:US
Practice Address - Phone:617-436-3200
Practice Address - Fax:617-436-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11044225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPT0171Medicare ID - Type Unspecified