Provider Demographics
NPI:1619923026
Name:SPORTS AND SPINE PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:SPORTS AND SPINE PHYSICAL THERAPY INC
Other - Org Name:SPORTSPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-593-7070
Mailing Address - Street 1:3355 RICHMOND RD
Mailing Address - Street 2:SUITE 101A
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-4100
Mailing Address - Country:US
Mailing Address - Phone:216-593-7070
Mailing Address - Fax:
Practice Address - Street 1:3365 RICHMOND RD STE 110
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4171
Practice Address - Country:US
Practice Address - Phone:216-593-7070
Practice Address - Fax:216-593-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000314395OtherOH BLUE CROSS/ANTHEM
OH2452199Medicaid
DD3410OtherRAILROAD MEDICARE
OH9336551Medicare PIN