Provider Demographics
NPI:1619181930
Name:ORTHOPAEDIC & SPORTS PHYSICAL THERAPY CLINIC PA
Entity Type:Organization
Organization Name:ORTHOPAEDIC & SPORTS PHYSICAL THERAPY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-774-5710
Mailing Address - Street 1:1601 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2102
Mailing Address - Country:US
Mailing Address - Phone:207-774-5710
Mailing Address - Fax:
Practice Address - Street 1:1601 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2102
Practice Address - Country:US
Practice Address - Phone:207-774-5710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2015-11-23
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
MEMM7586Medicare PIN