Provider Demographics
NPI:1871716514
Name:NEWBERRY PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC INC
Entity type:Organization
Organization Name:NEWBERRY PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WALDROP
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:803-276-7370
Mailing Address - Street 1:2515 EVANS ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2939
Mailing Address - Country:US
Mailing Address - Phone:803-276-7370
Mailing Address - Fax:803-276-7369
Practice Address - Street 1:2515 EVANS ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2939
Practice Address - Country:US
Practice Address - Phone:803-276-7370
Practice Address - Fax:803-276-7369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0650Medicaid