Provider Demographics
NPI:1902003650
Name:WESTPORT PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:WESTPORT PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RPT
Authorized Official - Phone:203-454-4438
Mailing Address - Street 1:185 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-3204
Mailing Address - Country:US
Mailing Address - Phone:203-454-4438
Mailing Address - Fax:203-454-0459
Practice Address - Street 1:185 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3204
Practice Address - Country:US
Practice Address - Phone:203-454-4438
Practice Address - Fax:203-454-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0034192251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03330Medicare PIN