Provider Demographics
NPI:1740248996
Name:PORT CITY PHYSICAL THERAPY
Entity type:Organization
Organization Name:PORT CITY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:M ED ATC
Authorized Official - Phone:617-515-5915
Mailing Address - Street 1:94 AUBURN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-797-7578
Mailing Address - Fax:207-797-8165
Practice Address - Street 1:94 AUBURN ST
Practice Address - Street 2:SUITE 103 PORT CITY PHYSICAL THERAPY
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-797-7578
Practice Address - Fax:207-797-8165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT2332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty