Provider Demographics
NPI:1396926416
Name:NORTHSIDE REHABILITATION
Entity type:Organization
Organization Name:NORTHSIDE REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:330-664-1600
Mailing Address - Street 1:150 SPRINGSIDE DRIVE
Mailing Address - Street 2:SUITE B250
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4572
Mailing Address - Country:US
Mailing Address - Phone:330-664-1600
Mailing Address - Fax:330-664-1606
Practice Address - Street 1:150 SPRINGSIDE DRIVE
Practice Address - Street 2:SUITE B250
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-4572
Practice Address - Country:US
Practice Address - Phone:330-664-1600
Practice Address - Fax:330-664-1606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT7378261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2430113Medicaid
OH2430140Medicaid
OHNO9335931Medicare PIN
OH2430113Medicaid