Provider Demographics
NPI:1104805977
Name:MIDWEST PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:MIDWEST PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PT PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BURKE
Authorized Official - Last Name:HOLTE
Authorized Official - Suffix:
Authorized Official - Credentials:PT OCS CSCS
Authorized Official - Phone:319-545-4104
Mailing Address - Street 1:2431 CORAL CT
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2838
Mailing Address - Country:US
Mailing Address - Phone:319-545-4104
Mailing Address - Fax:319-545-4105
Practice Address - Street 1:2431 CORAL CT
Practice Address - Street 2:SUITE 2
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2838
Practice Address - Country:US
Practice Address - Phone:319-545-4104
Practice Address - Fax:319-545-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1104805977Medicaid
IAI8406Medicare ID - Type Unspecified