Provider Demographics
NPI:1962685388
Name:1ST ADVANTAGE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:1ST ADVANTAGE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:219-663-3554
Mailing Address - Street 1:1516 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2332
Mailing Address - Country:US
Mailing Address - Phone:219-226-1500
Mailing Address - Fax:219-226-0500
Practice Address - Street 1:1516 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-2332
Practice Address - Country:US
Practice Address - Phone:219-226-1500
Practice Address - Fax:219-226-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005012A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000363591OtherANTHEM
INP00374932OtherRAILROAD MEDICARE
IN230220Medicare PIN