Provider Demographics
NPI:1740637826
Name:PODIUM LLC
Entity type:Organization
Organization Name:PODIUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:BONECUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:419-982-0062
Mailing Address - Street 1:20 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1614
Mailing Address - Country:US
Mailing Address - Phone:419-982-0062
Mailing Address - Fax:
Practice Address - Street 1:20 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1614
Practice Address - Country:US
Practice Address - Phone:419-982-0062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT016306261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy