Provider Demographics
NPI:1851518997
Name:PHYSICAL THERAPY SERVICES OF WILMINGTON
Entity Type:Organization
Organization Name:PHYSICAL THERAPY SERVICES OF WILMINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-763-8286
Mailing Address - Street 1:1776 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6442
Mailing Address - Country:US
Mailing Address - Phone:910-763-8286
Mailing Address - Fax:910-251-9289
Practice Address - Street 1:1776 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6442
Practice Address - Country:US
Practice Address - Phone:910-763-8286
Practice Address - Fax:910-251-9289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225100000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0176FOtherBCBS OF NC
NC7210839Medicaid
NCL2827OtherRAILROAD MEDICARE
NC2503426Medicare ID - Type Unspecified