Provider Demographics
NPI:1427002831
Name:PROFESSIONAL PHYSICAL THERAPY & SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY & SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REHAB/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAYBUCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MS, OCS
Authorized Official - Phone:508-528-6100
Mailing Address - Street 1:620 OLD WEST CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-2912
Mailing Address - Country:US
Mailing Address - Phone:508-528-6100
Mailing Address - Fax:508-528-6304
Practice Address - Street 1:620 OLD WEST CENTRAL ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-2912
Practice Address - Country:US
Practice Address - Phone:508-528-6100
Practice Address - Fax:508-528-6304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2019-05-03
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
MA605813OtherHARVARD-PILGRIM HEALTHPLA
MAY65686OtherBLUE CROSS OF MA
MA726552OtherTUFTS HEALTHPLAN
MA605813OtherHARVARD-PILGRIM HEALTHPLA