Provider Demographics
NPI:1548235351
Name:SUCCESS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SUCCESS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-874-7992
Mailing Address - Street 1:43 BAXTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-1823
Mailing Address - Country:US
Mailing Address - Phone:207-874-7992
Mailing Address - Fax:207-774-9156
Practice Address - Street 1:43 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1823
Practice Address - Country:US
Practice Address - Phone:207-874-7992
Practice Address - Fax:207-774-9156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME016708OtherANTHEM PROVIDER NUMBER
ME1041654OtherAETNA PROVIDER #
MEMN 2183OtherHARVARD IDENTIFICATION #