Provider Demographics
NPI:1811923535
Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KRAUSE ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PT/ATC
Authorized Official - Phone:218-641-7725
Mailing Address - Street 1:430 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1426
Mailing Address - Country:US
Mailing Address - Phone:218-641-7725
Mailing Address - Fax:218-641-6625
Practice Address - Street 1:430 5TH ST N
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1426
Practice Address - Country:US
Practice Address - Phone:218-641-7725
Practice Address - Fax:218-641-6625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6521225100000X
ND1180225100000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121G4OROtherMN BCBS FOR OT'S
MN148478000Medicaid
MNDD3739OtherRR MEDICARE
MN96570OtherHEALTH PARTNERS
ND1458152Medicaid
MN057K80ROtherMN BCBS
MN101592300OtherUS DEPT OF LABOR
MN1041486OtherPREFERRED ONE
MN96570OtherHEALTH PARTNERS
ND1458152Medicaid