Provider Demographics
NPI:1669672242
Name:INDY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:INDY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MPT
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MANZELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-849-3517
Mailing Address - Street 1:5250 E US HIGHWAY 36
Mailing Address - Street 2:STE 420
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9199
Mailing Address - Country:US
Mailing Address - Phone:317-849-3517
Mailing Address - Fax:317-849-6397
Practice Address - Street 1:5250 E US HIGHWAY 36
Practice Address - Street 2:STE 420
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9199
Practice Address - Country:US
Practice Address - Phone:317-849-3517
Practice Address - Fax:317-849-6397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN53000103A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000505369OtherANTHEM/BCBS
IN248320Medicare PIN