Provider Demographics
NPI:1720162662
Name:SOUTHERN PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:SOUTHERN PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MASTALERZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:931-388-8500
Mailing Address - Street 1:1810 SHADY BROOK ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3993
Mailing Address - Country:US
Mailing Address - Phone:931-388-8500
Mailing Address - Fax:
Practice Address - Street 1:1810 SHADY BROOK ST
Practice Address - Street 2:SUITE 3
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3993
Practice Address - Country:US
Practice Address - Phone:931-388-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT2044225100000X
TNPT6832225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3723207Medicaid
TN3723207Medicaid