Provider Demographics
NPI:1497948509
Name:MCDONALD REHAB, PC
Entity Type:Organization
Organization Name:MCDONALD REHAB, PC
Other - Org Name:SUPERIOR PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BART
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-233-2248
Mailing Address - Street 1:1800 FLANDRO DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4940
Mailing Address - Country:US
Mailing Address - Phone:208-233-2248
Mailing Address - Fax:208-233-0219
Practice Address - Street 1:1800 FLANDRO DR
Practice Address - Street 2:SUITE 190
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4940
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:208-233-0219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1555225100000X
IDOT-884225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7869690OtherAETNA
ID807980200Medicaid
IDP00320548OtherBLUE SHIELD MEDICARE ADVA
IDT9345OtherBCID
ID807980200Medicaid