Provider Demographics
NPI:1629134234
Name:DYNAMIC REHAB PHYSICAL THERAPY
Entity Type:Organization
Organization Name:DYNAMIC REHAB PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ESSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FATHY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:615-459-9800
Mailing Address - Street 1:211 COMMERCE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-3024
Mailing Address - Country:US
Mailing Address - Phone:615-459-9800
Mailing Address - Fax:615-459-2500
Practice Address - Street 1:211 COMMERCE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3024
Practice Address - Country:US
Practice Address - Phone:615-459-9800
Practice Address - Fax:615-459-2500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000001078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3106299OtherBCBS
TN3106299OtherBCBS