Provider Demographics
NPI:1538381819
Name:DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:DELTA PHYSICAL THERAPY AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:419-822-4100
Mailing Address - Street 1:816 MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:DELTA
Mailing Address - State:OH
Mailing Address - Zip Code:43515-1462
Mailing Address - Country:US
Mailing Address - Phone:419-822-4100
Mailing Address - Fax:419-822-0334
Practice Address - Street 1:816 MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:DELTA
Practice Address - State:OH
Practice Address - Zip Code:43515-1462
Practice Address - Country:US
Practice Address - Phone:419-822-4100
Practice Address - Fax:419-822-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2467174Medicaid
OHAN4125391Medicare ID - Type Unspecified
OHDE9341531Medicare ID - Type Unspecified