Provider Demographics
NPI:1538250642
Name:CENTER FOR PHYSICAL THERAPY & SPORTS REHAB
Entity type:Organization
Organization Name:CENTER FOR PHYSICAL THERAPY & SPORTS REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERDT
Authorized Official - Middle Name:
Authorized Official - Last Name:PROPFE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:860-446-8254
Mailing Address - Street 1:495 GOLD STAR HWY
Mailing Address - Street 2:SUITE 112
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6803
Mailing Address - Country:US
Mailing Address - Phone:860-446-8254
Mailing Address - Fax:860-446-8293
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:SUITE 112
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6803
Practice Address - Country:US
Practice Address - Phone:860-446-8254
Practice Address - Fax:860-446-8293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0V1692OtherHEALTH NET
CT080001847CT01OtherANTHEM BLUE CROSS