Provider Demographics
NPI:1194732214
Name:PMD THERAPIES, PLLC
Entity type:Organization
Organization Name:PMD THERAPIES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:DYE
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, MOTR/L, ATC
Authorized Official - Phone:208-356-0174
Mailing Address - Street 1:36 WINN DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-0174
Mailing Address - Fax:208-356-0176
Practice Address - Street 1:36 WINN DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-0174
Practice Address - Fax:208-356-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1920174400000X, 225100000X
IDOT-711174400000X, 225X00000X
IDAT-142174400000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID887408OtherDMBA
IDTC134OtherBLUE CROSS CLINIC
IDTC142OtherBLUE CROSS PT
ID807252700Medicaid
IDTC142OtherBLUE CROSS PT
ID807252700Medicaid
ID887408OtherDMBA
ID1379768Medicare ID - Type UnspecifiedGROUP OT
ID1551725Medicare ID - Type UnspecifiedIND OT