Provider Demographics
NPI:1619979226
Name:PHYSICIANS TOTAL REHAB OF FAYETTEVILLE INC.
Entity Type:Organization
Organization Name:PHYSICIANS TOTAL REHAB OF FAYETTEVILLE INC.
Other - Org Name:PHYSICANS TOTAL REHAB OF FAYETTEVILLE, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ZANE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:910-323-9010
Mailing Address - Street 1:2930 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3815
Mailing Address - Country:US
Mailing Address - Phone:910-323-9010
Mailing Address - Fax:910-323-9568
Practice Address - Street 1:2930 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3815
Practice Address - Country:US
Practice Address - Phone:910-323-9010
Practice Address - Fax:910-323-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39135208100000X
NC225100000X, 225X00000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0104POtherBCBS NC
NC932583OtherMAILHANDLERS
NC7200229Medicaid
NC6438888OtherPHYSICIANS HEALTH PLAN
NY248124OtherMAMSI
NC7200229Medicaid