Provider Demographics
NPI:1184670028
Name:COMMONWEALTH REHABILITATION AND SPORTS MEDICINE, P.S.C.
Entity type:Organization
Organization Name:COMMONWEALTH REHABILITATION AND SPORTS MEDICINE, P.S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:419-537-0764
Mailing Address - Street 1:3425 EXECUTIVE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1333
Mailing Address - Country:US
Mailing Address - Phone:419-537-0764
Mailing Address - Fax:419-537-0948
Practice Address - Street 1:193 GLADES RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1369
Practice Address - Country:US
Practice Address - Phone:859-986-1055
Practice Address - Fax:859-986-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
412190836-02OtherOHIO BWC
611270800OtherDEPARTMENT OF LABOR/OWCP
KY8790053600Medicaid
KY00512Medicare PIN