Provider Demographics
NPI:1245256817
Name:PHYSIOSOURCE LTD.
Entity type:Organization
Organization Name:PHYSIOSOURCE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:419-724-5580
Mailing Address - Street 1:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-0878
Mailing Address - Country:US
Mailing Address - Phone:419-724-5580
Mailing Address - Fax:419-724-5581
Practice Address - Street 1:3840 WOODLEY RD.
Practice Address - Street 2:SUITE D
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1178
Practice Address - Country:US
Practice Address - Phone:419-724-5580
Practice Address - Fax:419-724-5581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT07759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000285765OtherANTHEM BC/BS
OH2419743Medicaid
OHDD2140OtherRAILROAD MEDICARE
OH731071OtherBUCKEYE COMMUNITY HEALTH
OH498394182OtherMEDICAL MUTUAL OF OHIO
OH362488800OtherDEPARTMENT OF LABOR
OH498394182OtherMEDICAL MUTUAL OF OHIO