Provider Demographics
NPI:1760414031
Name:FROMDAHL, JEFFREY (MSPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FROMDAHL
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 WEST SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655
Mailing Address - Country:US
Mailing Address - Phone:770-207-6624
Mailing Address - Fax:770-207-6631
Practice Address - Street 1:1219 WEST SPRING STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655
Practice Address - Country:US
Practice Address - Phone:770-207-6624
Practice Address - Fax:770-207-6631
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC187186OtherMEDCOST PROVIDER NUMBER
SCP00163187OtherRAILROAD MEDICARE NUMBER
SC187186OtherMEDCOST PROVIDER NUMBER
SCQ332547620Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER