Provider Demographics
NPI:1750312161
Name:ADVANCED PT LLC
Entity Type:Organization
Organization Name:ADVANCED PT LLC
Other - Org Name:ADVANCED PT MAPLE RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:BERTHA
Authorized Official - Last Name:ROSEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:316-944-0022
Mailing Address - Street 1:7130 W MAPLE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-2101
Mailing Address - Country:US
Mailing Address - Phone:316-944-0022
Mailing Address - Fax:316-944-0020
Practice Address - Street 1:200 W DOUGLAS AVE
Practice Address - Street 2:STE 1040
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3013
Practice Address - Country:US
Practice Address - Phone:316-263-0003
Practice Address - Fax:316-263-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-021269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS115692Medicare PIN