Provider Demographics
NPI:1225019805
Name:SPECIALIZED PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:SPECIALIZED PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:856-424-0993
Mailing Address - Street 1:1930 MARLTON PIKE E
Mailing Address - Street 2:A7
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2150
Mailing Address - Country:US
Mailing Address - Phone:856-424-0993
Mailing Address - Fax:
Practice Address - Street 1:1930 MARLTON PIKE E
Practice Address - Street 2:A7
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2150
Practice Address - Country:US
Practice Address - Phone:856-424-0993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ089321Medicare ID - Type UnspecifiedGROUP #