Provider Demographics
NPI:1548331861
Name:FREEPORT PHYSICAL THERAPY, PA
Entity type:Organization
Organization Name:FREEPORT PHYSICAL THERAPY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:HALDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:207-865-0004
Mailing Address - Street 1:303 US ROUTE 1
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-7007
Mailing Address - Country:US
Mailing Address - Phone:207-865-0004
Mailing Address - Fax:207-865-3004
Practice Address - Street 1:303 US ROUTE 1
Practice Address - Street 2:SUITE 1B
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-7007
Practice Address - Country:US
Practice Address - Phone:207-865-0004
Practice Address - Fax:207-865-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME7938937OtherAETNA
ME098822OtherANTHEM
MEAA88121OtherHARVARD PILGRIM
ME312660000Medicaid
ME3519267OtherCIGNA
ME7938937OtherAETNA