Provider Demographics
NPI:1497880215
Name:PRO REHAB, INC, PC
Entity Type:Organization
Organization Name:PRO REHAB, INC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPISTPRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:POTAMITIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MS
Authorized Official - Phone:978-452-6633
Mailing Address - Street 1:278 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-4121
Mailing Address - Country:US
Mailing Address - Phone:978-452-6633
Mailing Address - Fax:978-935-2741
Practice Address - Street 1:278 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-4121
Practice Address - Country:US
Practice Address - Phone:978-452-6633
Practice Address - Fax:978-935-2741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2012-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA136225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0305791Medicaid
MA0315702Medicaid
MA0305791Medicaid
MAY68853Medicare ID - Type UnspecifiedPHYSICAL THERAPY