Provider Demographics
NPI:1891890844
Name:JOHNS CREEK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:JOHNS CREEK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:C
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-622-5344
Mailing Address - Street 1:4060 JOHNS CREEK PARKWAY
Mailing Address - Street 2:SUITE H
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6122
Mailing Address - Country:US
Mailing Address - Phone:770-622-5344
Mailing Address - Fax:770-622-5388
Practice Address - Street 1:4060 JOHNS CREEK PARKWAY
Practice Address - Street 2:SUITE H
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6122
Practice Address - Country:US
Practice Address - Phone:770-622-5344
Practice Address - Fax:770-622-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006322225100000X
GA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT006322OtherPHYSICAL THERAPIST LICENS
GAGRP6161Medicare UPIN
GAPT006322OtherPHYSICAL THERAPIST LICENS