Provider Demographics
NPI:1518164102
Name:MATRIX REHABILITATION - GEORGIA, INC.
Entity Type:Organization
Organization Name:MATRIX REHABILITATION - GEORGIA, INC.
Other - Org Name:PROGRESSIVE SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-644-7824
Mailing Address - Street 1:665 PHILADELPHIA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3941
Mailing Address - Country:US
Mailing Address - Phone:724-465-3496
Mailing Address - Fax:724-465-3726
Practice Address - Street 1:5223 HIGHWAY 278 NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2671
Practice Address - Country:US
Practice Address - Phone:770-784-9932
Practice Address - Fax:770-784-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116814Medicare Oscar/Certification