Provider Demographics
NPI:1568412708
Name:PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDRIA
Authorized Official - Middle Name:JEAN MARIE
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:918-649-0799
Mailing Address - Street 1:1932 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-649-0799
Mailing Address - Fax:918-649-0797
Practice Address - Street 1:1932 N BROADWAY
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953
Practice Address - Country:US
Practice Address - Phone:918-649-0799
Practice Address - Fax:918-649-0797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2012-02-10
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
OK200006850AMedicaid
OKDD4017OtherRR MEDICARE
OKDD4017OtherRR MEDICARE
OK700522151Medicare PIN