Provider Demographics
NPI:1972671352
Name:SHIPPENSBURG PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:SHIPPENSBURG PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:717-477-8030
Mailing Address - Street 1:20 PARK PL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-9806
Mailing Address - Country:US
Mailing Address - Phone:717-477-8030
Mailing Address - Fax:717-477-8040
Practice Address - Street 1:20 PARK PL
Practice Address - Street 2:SUITE 2
Practice Address - City:SHIPPENSBURG
Practice Address - State:PA
Practice Address - Zip Code:17257-9806
Practice Address - Country:US
Practice Address - Phone:717-477-8030
Practice Address - Fax:717-477-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023274600001Medicaid
PA108735Medicare PIN