Provider Demographics
NPI:1730188350
Name:SHERIDAN PHYSICAL THERAPY CLINIC
Entity type:Organization
Organization Name:SHERIDAN PHYSICAL THERAPY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR AND OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:SAENGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:870-942-8335
Mailing Address - Street 1:15 OPPORTUNITY DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-9185
Mailing Address - Country:US
Mailing Address - Phone:870-942-8335
Mailing Address - Fax:870-942-2234
Practice Address - Street 1:15 OPPORTUNITY DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-9185
Practice Address - Country:US
Practice Address - Phone:870-942-8335
Practice Address - Fax:870-942-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT8602251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S214OtherBCBS - INDIVIDUAL
AR133355742Medicaid
AR123181721Medicaid
AR5C043Medicare PIN
AR650008306Medicare PIN