Provider Demographics
NPI:1598775694
Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE OF SHAWANO LLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE OF SHAWANO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:WORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-991-2561
Mailing Address - Street 1:212 E GREEN BAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166
Mailing Address - Country:US
Mailing Address - Phone:715-526-5221
Mailing Address - Fax:715-526-2542
Practice Address - Street 1:212 E GREEN BAY ST
Practice Address - Street 2:SUITE A
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166
Practice Address - Country:US
Practice Address - Phone:715-526-5221
Practice Address - Fax:715-526-2542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
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