Provider Demographics
NPI:1649445438
Name:SOUTHEAST OHIO SPORTS MEDICINE AND PHYSICAL THERAPY
Entity type:Organization
Organization Name:SOUTHEAST OHIO SPORTS MEDICINE AND PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:740-592-6900
Mailing Address - Street 1:215 COLUMBUS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1335
Mailing Address - Country:US
Mailing Address - Phone:740-592-6900
Mailing Address - Fax:740-593-3530
Practice Address - Street 1:215 COLUMBUS RD STE 101
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1335
Practice Address - Country:US
Practice Address - Phone:740-592-6900
Practice Address - Fax:740-593-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1284174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9300111Medicare PIN