Provider Demographics
NPI:1215167515
Name:SOUTHERN REHAB AND SPORTS MEDICINE, INC.
Entity type:Organization
Organization Name:SOUTHERN REHAB AND SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCGINTY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:706-845-9383
Mailing Address - Street 1:1805 VERNON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3871
Mailing Address - Country:US
Mailing Address - Phone:706-845-9383
Mailing Address - Fax:706-845-9482
Practice Address - Street 1:1805 VERNON RD STE A
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3871
Practice Address - Country:US
Practice Address - Phone:706-845-9383
Practice Address - Fax:706-845-9482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8954261QP2000X
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6349170001Medicare NSC