Provider Demographics
NPI:1912086158
Name:BRIDGEPORT PHYSICAL THERAPY SERVICES, INC.
Entity Type:Organization
Organization Name:BRIDGEPORT PHYSICAL THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:T.
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:304-842-3137
Mailing Address - Street 1:306 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1751
Mailing Address - Country:US
Mailing Address - Phone:304-842-3137
Mailing Address - Fax:304-842-3138
Practice Address - Street 1:306 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1751
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0201604000Medicaid
WV0201604000Medicaid