Provider Demographics
NPI:1710122791
Name:PHYSICAL THERAPY FORUM
Entity Type:Organization
Organization Name:PHYSICAL THERAPY FORUM
Other - Org Name:PT FORUM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-431-1301
Mailing Address - Street 1:5755 NORTHPOINT PKWY
Mailing Address - Street 2:SUITE 56
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1142
Mailing Address - Country:US
Mailing Address - Phone:678-431-1301
Mailing Address - Fax:
Practice Address - Street 1:5755 NORTHPOINT PKWY
Practice Address - Street 2:SUITE 56
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1142
Practice Address - Country:US
Practice Address - Phone:678-431-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005421261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy