Provider Demographics
NPI:1578791042
Name:NORTH SOUTH PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:NORTH SOUTH PHYSICAL THERAPY, INC
Other - Org Name:MAIN STREET PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GAROFALO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:508-559-9696
Mailing Address - Street 1:95 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4010
Mailing Address - Country:US
Mailing Address - Phone:508-559-9696
Mailing Address - Fax:508-559-9751
Practice Address - Street 1:95 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4010
Practice Address - Country:US
Practice Address - Phone:508-559-9696
Practice Address - Fax:508-559-9751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA124225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0029723OtherNEIGHBORHOOD HEALTH
MAAA9360OtherHARVARD PILGRIM HEALTH INSURANCE
7380356OtherAETNA
MA9786082Medicaid
MAY61200OtherBLUE CROSS BLUE SHIELD
MAY61200OtherBLUE CROSS BLUE SHIELD