Provider Demographics
NPI:1801812482
Name:IRONWOOD DRIVE PHYSICAL THERAPY, PA
Entity type:Organization
Organization Name:IRONWOOD DRIVE PHYSICAL THERAPY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-667-6264
Mailing Address - Street 1:1450 NORTHWEST BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5605
Mailing Address - Country:US
Mailing Address - Phone:208-667-6264
Mailing Address - Fax:208-664-4313
Practice Address - Street 1:1450 NORTHWEST BLVD STE 106
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5605
Practice Address - Country:US
Practice Address - Phone:208-667-6264
Practice Address - Fax:208-664-4313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002769000Medicaid
ID1652708Medicare ID - Type Unspecified