Provider Demographics
NPI:1972780187
Name:ADVANCED PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:608-249-6239
Mailing Address - Street 1:PO BOX 1272
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:WY
Mailing Address - Zip Code:82331-1272
Mailing Address - Country:US
Mailing Address - Phone:608-345-7053
Mailing Address - Fax:
Practice Address - Street 1:207 E HOLLY
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:WY
Practice Address - Zip Code:82331
Practice Address - Country:US
Practice Address - Phone:307-326-8223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9632-024261QP2000X
WYPT-1763261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40358600Medicaid
WI41570000OtherMEDICAID DME
WI41570000OtherMEDICAID DME