Provider Demographics
NPI:1508053364
Name:WEST SIDE MEDICAL AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:WEST SIDE MEDICAL AND PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHENKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-592-9432
Mailing Address - Street 1:4780 ASHFORD DUNWOODY RD
Mailing Address - Street 2:SUITE A-617
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5564
Mailing Address - Country:US
Mailing Address - Phone:866-592-9432
Mailing Address - Fax:
Practice Address - Street 1:4780 ASHFORD DUNWOODY RD
Practice Address - Street 2:SUITE A-617
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-5564
Practice Address - Country:US
Practice Address - Phone:866-592-9432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty