Provider Demographics
NPI:1700820941
Name:PHYSICAL MEDICINE LLC
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-656-8800
Mailing Address - Street 1:1424 E FOREMASTER DR # 120
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-656-8800
Mailing Address - Fax:435-627-1809
Practice Address - Street 1:1424 E FOREMASTER DR # 120
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-656-8800
Practice Address - Fax:435-627-1809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17657112052081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055494Medicare ID - Type UnspecifiedPHYSICAL MEDICINE GROUP #