Provider Demographics
NPI:1316148992
Name:MIDLAND PHYSICAL THERAPY AND SPORTS REHABILITATION INC
Entity type:Organization
Organization Name:MIDLAND PHYSICAL THERAPY AND SPORTS REHABILITATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STREETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-699-9395
Mailing Address - Street 1:PO BOX 932184
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2420 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6337
Practice Address - Country:US
Practice Address - Phone:432-687-0235
Practice Address - Fax:432-570-8713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPT158345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82979TOtherBLUE CROSS BLUE SHIELDS
TX456688Medicare ID - Type Unspecified