Provider Demographics
NPI:1447337423
Name:NORTHEASTERN PHYSICAL REHAB, INC.
Entity type:Organization
Organization Name:NORTHEASTERN PHYSICAL REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:918-458-5115
Mailing Address - Street 1:1500 E DOWNING ST STE 210
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3379
Mailing Address - Country:US
Mailing Address - Phone:918-458-5115
Mailing Address - Fax:818-458-5119
Practice Address - Street 1:1500 E DOWNING ST STE 210
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3379
Practice Address - Country:US
Practice Address - Phone:918-458-5115
Practice Address - Fax:818-458-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK175254900OtherDEPT OF LABOR
OK200022640Medicaid
OK650020254OtherRR MEDICARE
OK=========001OtherBCBS
OK175254900OtherDEPT OF LABOR
OK=========001OtherBCBS