Provider Demographics
NPI:1497973176
Name:SUMMIT PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:SUMMIT PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:304-527-4472
Mailing Address - Street 1:414 PENCO RD
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3822
Mailing Address - Country:US
Mailing Address - Phone:304-723-3780
Mailing Address - Fax:304-723-4110
Practice Address - Street 1:1425 MAIN ST
Practice Address - Street 2:
Practice Address - City:FOLLANSBEE
Practice Address - State:WV
Practice Address - Zip Code:26037-1217
Practice Address - Country:US
Practice Address - Phone:304-527-4472
Practice Address - Fax:304-572-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004834Medicaid
WV=========OtherTAX ID
WV9300702Medicare PIN
WVCC4728Medicare PIN