Provider Demographics
NPI:1679578017
Name:KEVIN LAURENCE OUTWATER
Entity Type:Organization
Organization Name:KEVIN LAURENCE OUTWATER
Other - Org Name:PT CTR FOR SPORTS MED-FAM PHYS THER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTWATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-239-4186
Mailing Address - Street 1:2660 W MARKET ST
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4206
Mailing Address - Country:US
Mailing Address - Phone:330-869-2635
Mailing Address - Fax:330-869-8315
Practice Address - Street 1:2660 W MARKET ST
Practice Address - Street 2:STE 300
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4206
Practice Address - Country:US
Practice Address - Phone:330-869-2635
Practice Address - Fax:330-869-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT04320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9301851Medicare PIN
OH9301851Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER