Provider Demographics
NPI:1548219447
Name:SPRINGFIELD PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SPRINGFIELD PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MEMBER PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:417-888-0808
Mailing Address - Street 1:929 E MONTCLAIR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807
Mailing Address - Country:US
Mailing Address - Phone:417-888-0808
Mailing Address - Fax:417-888-0811
Practice Address - Street 1:929 E MONTCLAIR
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-888-0808
Practice Address - Fax:417-888-0811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO169735OtherBCBS
MODC9496OtherRAILROAD MEDICARE
MO990001809Medicare ID - Type Unspecified