Provider Demographics
NPI:1629146857
Name:NORTHRUP PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:NORTHRUP PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHRUP
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-221-6952
Mailing Address - Street 1:4473 FOX CT
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2670
Mailing Address - Country:US
Mailing Address - Phone:208-221-6952
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:4473 FOX CT
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2670
Practice Address - Country:US
Practice Address - Phone:208-221-6952
Practice Address - Fax:208-236-6695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1654146Medicare ID - Type Unspecified