Basic Information
| Provider Information | |||||||||
| NPI: | 1013014208 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATLANTA SOUTH PHYSICAL THERAPY, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHAB SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 EAGLES LANDING PKWY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782890525 | ||||||||
| FaxNumber: | 6782890529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAGE | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4232387217 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | DD7784 | 01 | GA | RAILROAD MEDICARE GROUP PROVIDER # | OTHER |