Provider Demographics
NPI:1386703395
Name:THE SIDELINE PHYSICAL THERAPY
Entity type:Organization
Organization Name:THE SIDELINE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:WRAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:731-587-3422
Mailing Address - Street 1:104 OXFORD ST
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-2428
Mailing Address - Country:US
Mailing Address - Phone:731-587-3422
Mailing Address - Fax:731-587-3424
Practice Address - Street 1:104 OXFORD ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-2428
Practice Address - Country:US
Practice Address - Phone:731-587-3422
Practice Address - Fax:731-587-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717871Medicare ID - Type Unspecified