Provider Demographics
NPI:1063406544
Name:FREEDOM PHYSICAL THERAPY SERVICES SC
Entity type:Organization
Organization Name:FREEDOM PHYSICAL THERAPY SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:STATHAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-352-2082
Mailing Address - Street 1:6908 N SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3942
Mailing Address - Country:US
Mailing Address - Phone:414-352-2082
Mailing Address - Fax:414-352-5279
Practice Address - Street 1:6908 N SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:FOX POINT
Practice Address - State:WI
Practice Address - Zip Code:53217-3942
Practice Address - Country:US
Practice Address - Phone:414-352-2082
Practice Address - Fax:414-352-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40418500Medicaid
WI40418500Medicaid
WI000085185Medicare PIN