Provider Demographics
NPI:1841418001
Name:PRIME PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:PRIME PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:813-932-3315
Mailing Address - Street 1:PO BOX 272689
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-2689
Mailing Address - Country:US
Mailing Address - Phone:813-932-3315
Mailing Address - Fax:813-935-9835
Practice Address - Street 1:7815 N DALE MABRY HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3203
Practice Address - Country:US
Practice Address - Phone:813-932-3315
Practice Address - Fax:813-935-9835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18611174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7822407OtherAETNA PPO
FL222534Medicaid
FL2906996OtherCIGNA
FL3041824OtherAETNA HMO
FLY0571OtherBCBS
FL7822407OtherAETNA PPO
FLK3223Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER