Provider Demographics
NPI:1083827406
Name:SPORTHOPEDICS PHYSICAL THERAPY, PC
Entity type:Organization
Organization Name:SPORTHOPEDICS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:P
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-776-2035
Mailing Address - Street 1:1060 CRATER LAKE AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-776-2035
Mailing Address - Fax:541-776-2036
Practice Address - Street 1:1060 CRATER LAKE AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-776-2035
Practice Address - Fax:541-776-2036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025186000OtherREGENCE BLUECROSS BLUE SH
OR230485Medicaid
ORR107222Medicare ID - Type UnspecifiedGROUP NUMBER