Provider Demographics
NPI:1790039667
Name:ELIZABETHTOWN PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ELIZABETHTOWN PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-972-1100
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:LEGAL DEPARTMENT
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-972-1100
Mailing Address - Fax:
Practice Address - Street 1:101 N EAGLE CREEK DR STE 110
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1806
Practice Address - Country:US
Practice Address - Phone:859-294-8320
Practice Address - Fax:859-299-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP100016234Medicare PIN