Basic Information
| Provider Information | |||||||||
| NPI: | 1578815973 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PT CENTER FOR SPORTS MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2660 W MARKET ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443334209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308692635 | ||||||||
| FaxNumber: | 3308698315 | ||||||||
| Practice Location | |||||||||
| Address1: | 2660 W MARKET ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | FAIRLAWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443334209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308692635 | ||||||||
| FaxNumber: | 3308698315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2012 | ||||||||
| LastUpdateDate: | 10/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | OUTWATER | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3308692635 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 003349 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.