Provider Demographics
NPI:1790804326
Name:PROFESSIONAL PHYSICAL THERAPY SERVICES, INC
Entity Type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY SERVICES, INC
Other - Org Name:SPORTS THERAPY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:Z
Authorized Official - Last Name:NOVICKI
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:513-671-5841
Mailing Address - Street 1:11729 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2311
Mailing Address - Country:US
Mailing Address - Phone:513-671-5841
Mailing Address - Fax:513-671-5106
Practice Address - Street 1:5700 GATEWAY
Practice Address - Street 2:SUITE 100A
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1890
Practice Address - Country:US
Practice Address - Phone:513-336-0540
Practice Address - Fax:513-336-6064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2927293Medicaid
OH2927293Medicaid