Provider Demographics
NPI:1578518718
Name:SPECIALIZED ORTHOPEDIC PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:SPECIALIZED ORTHOPEDIC PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:ULISSE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:401-384-6490
Mailing Address - Street 1:250A CENTERVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:401-384-6490
Mailing Address - Fax:401-384-6493
Practice Address - Street 1:250A CENTERVILLE ROAD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-384-6490
Practice Address - Fax:401-384-6493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2014-12-18
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
659081075Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER