Provider Demographics
NPI:1255369963
Name:OLYMPIC PHYSICAL MEDICINE
Entity type:Organization
Organization Name:OLYMPIC PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, LATC, CSCS
Authorized Official - Phone:617-666-8800
Mailing Address - Street 1:200 MAIN STREET
Mailing Address - Street 2:111
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1619
Mailing Address - Country:US
Mailing Address - Phone:617-666-8800
Mailing Address - Fax:617-666-4488
Practice Address - Street 1:200 MAIN STREET
Practice Address - Street 2:111
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1619
Practice Address - Country:US
Practice Address - Phone:617-666-8800
Practice Address - Fax:617-666-4488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY61424OtherBC/BS
MA0035582OtherNEIGHBORHOOD HEALTH
MAAA36064OtherHARVARD PILGRIM
MA2752329OtherAETNA
MAY61424OtherBC/BS
MA2752329OtherAETNA
MA=========OtherUNITED
MAY61424OtherBC/BS