Provider Demographics
NPI:1730336314
Name:PADBERG, DYLAN ANTHONY (PT, DPT)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:ANTHONY
Last Name:PADBERG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:14802 SHAMROCK WAY STE C
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089-8381
Practice Address - Country:US
Practice Address - Phone:816-873-1101
Practice Address - Fax:816-399-5796
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1103880225100000X
MO2008032777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
41645082OtherBCBS KC
MOMA4370046OtherMEDICARE PTAN
KS1730336314OtherBCBS KS
KSKA2868007OtherMEDICARE PTAN
MOW12000005Medicare PIN
MOP75000005Medicare PIN
MOT66A00002Medicare PIN