Provider Demographics
NPI:1730356742
Name:INDEPENDENT PHYSICAL THERAPY
Entity type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-2313
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:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:7693 RHEA COUNTY HWY STE 2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-6083
Practice Address - Country:US
Practice Address - Phone:423-570-0907
Practice Address - Fax:423-570-0936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156797OtherBCBST GROUP #
TN0446652Medicaid
TN0446652Medicaid