MEDICARE: NEUROSPORT PHYSICAL THERAPY & REHABILITATION SPECIALIST INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	003709	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	650016944	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	5093346	OTHER	AETNA PPO, MC
2	606717	OTHER	AETNA HMO
3	52266108	OTHER	BCBS OF GEORGIA

General Provider Information

NPI Number	:	1376546341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROSPORT PHYSICAL THERAPY & REHABILITATION SPECIALIST INC.

Provider Business Mailing Address
First Line	:	1163 JOHNSON FERRY RD
Second Line	:	STE 100
City	:	MARIETTA
State	:	GA
Zip	:	30068-2764
Country	:	US
Telephone Number	:	770-321-0155
Fax Number	:	770-321-8426

Provider Business Practice Location Address
First Line	:	1163 JOHNSON FERRY RD
Second Line	:	STE 100
City	:	MARIETTA
State	:	GA
Zip	:	30068-2764
Country	:	US
Telephone Number	:	770-321-0155
Fax Number	:	770-321-8426

Authorized Official
Title or Position	:	REGIONAL OFFICE MANAGER
Name	:	MISS MORIAH MORGAN
Credential	:
Telephone Number	:	770-321-0155

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/16/2014

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