Provider Demographics
NPI:1871738872
Name:PERFORMANCE PHYSICAL THERAPY & SPORTS MEDICINE INC
Entity type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY & SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BERTON
Authorized Official - Last Name:GIDDENS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-748-0309
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0528
Mailing Address - Country:US
Mailing Address - Phone:706-638-3880
Mailing Address - Fax:706-638-3890
Practice Address - Street 1:106 PEARL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-7509
Practice Address - Country:US
Practice Address - Phone:706-638-3880
Practice Address - Fax:706-638-3890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G701145Medicare PIN