Provider Demographics
NPI:1104800655
Name:SYVERTSON, GREGORY STUART (PT, DPT, CFT,CCI)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:STUART
Last Name:SYVERTSON
Suffix:
Gender:M
Credentials:PT, DPT, CFT,CCI
Other - Prefix:DR
Other - First Name:GREG
Other - Middle Name:S
Other - Last Name:SYVERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT, CFT,CCI
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-0767
Mailing Address - Country:US
Mailing Address - Phone:304-252-4170
Mailing Address - Fax:304-252-4175
Practice Address - Street 1:1 JOHN RAINE DR
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-1457
Practice Address - Country:US
Practice Address - Phone:304-438-9225
Practice Address - Fax:304-438-9226
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0001489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5534228OtherFIRST HEALTH
WV612406500OtherDOL FECA
WV697891OtherUNITED HEALTH CARE
WV9420008-000Medicaid
WV1064530OtherBRICKSTREET WC
WV7239017OtherAETNA
WV001714553OtherMSBCBS INDIVIDUAL PIN
WV87316OtherUNICARE
WV697891OtherUNITED HEALTH CARE
WV87316OtherUNICARE