Provider Demographics
NPI:1598950206
Name:MAYTUM, THOMAS JOHN JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOHN
Last Name:MAYTUM
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1225 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2504
Mailing Address - Country:US
Mailing Address - Phone:706-272-6199
Mailing Address - Fax:706-272-6291
Practice Address - Street 1:1225 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2504
Practice Address - Country:US
Practice Address - Phone:706-272-6199
Practice Address - Fax:706-272-6291
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA001065225200000X
FLPTA15969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant