Provider Demographics
NPI:1164474342
Name:INDEPENDENT PHYSICAL THERAPY
Entity type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-7217
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:820 SCENIC HWY
Practice Address - Street 2:SUITE B
Practice Address - City:LOOKOUT MOUNTAIN
Practice Address - State:TN
Practice Address - Zip Code:37350-1471
Practice Address - Country:US
Practice Address - Phone:423-825-1393
Practice Address - Fax:423-825-6147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3655319Medicare PIN
TN3650060Medicare PIN