Provider Demographics
NPI:1104878354
Name:INDEPENDENT PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:INDEPENDENT PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP REVENUE CYCLE
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANNESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-8923
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4915
Mailing Address - Country:US
Mailing Address - Phone:423-238-8923
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:6397 LEE HWY STE 300
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4915
Practice Address - Country:US
Practice Address - Phone:423-238-8923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomicsGroup - Multi-Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446652Medicaid
TN3156797OtherBCBST
TN446652Medicare Oscar/Certification