Provider Demographics
NPI:1427259779
Name:PRIME PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:PRIME PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-932-3315
Mailing Address - Street 1:PO BOX 272689
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33688-2689
Mailing Address - Country:US
Mailing Address - Phone:813-932-3315
Mailing Address - Fax:
Practice Address - Street 1:4895 W WATERS AVE
Practice Address - Street 2:SUITE E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1316
Practice Address - Country:US
Practice Address - Phone:813-932-3315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2015-10-28
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
FL222535Medicaid
FL2906996OtherCIGNA
FL350376000OtherDEPT OF LABOR
FLY0571OtherNON-PAR BCBS
FL=========OtherAETNA
FLY0571OtherNON-PAR BCBS
FL222535Medicaid