Provider Demographics
NPI:1811014681
Name:THE CENTER FOR SPORTS & PHYSICAL THERAPY
Entity Type:Organization
Organization Name:THE CENTER FOR SPORTS & PHYSICAL THERAPY
Other - Org Name:THE CENTER GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PURDOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-674-4455
Mailing Address - Street 1:4411 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-5349
Mailing Address - Country:US
Mailing Address - Phone:765-674-4455
Mailing Address - Fax:765-674-3577
Practice Address - Street 1:4411 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-5349
Practice Address - Country:US
Practice Address - Phone:765-674-4455
Practice Address - Fax:765-674-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100124000CMedicaid
IN160774OtherIN CHILDREN SPECIAL HEALT
IN100124000BMedicaid
IN129137500OtherUS DEPT OF LABOR
IN100124000AMedicaid
IN100124000CMedicaid
IN0934170001Medicare NSC
IN100124000AMedicaid
IN160774OtherIN CHILDREN SPECIAL HEALT