Provider Demographics
NPI:1619191210
Name:NORTHCENTRAL IN SPORTS MEDICINE
Entity type:Organization
Organization Name:NORTHCENTRAL IN SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WEINSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-753-4063
Mailing Address - Street 1:80 HEARTLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-7684
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1603 CHASE RD
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1538
Practice Address - Country:US
Practice Address - Phone:574-737-7404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000392A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty