MEDICARE: INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM1300X	Multi-Specialty Clinic/Center
2	261QR0400X	Rehabilitation Clinic/Center
3	261QP2000X	Physical Therapy Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CK9205	OTHER	GA	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1457511289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	800 PEACHTREE ST NE
Second Line	:	STE E2
City	:	ATLANTA
State	:	GA
Zip	:	30308-1245
Country	:	US
Telephone Number	:	404-523-7709
Fax Number	:	404-523-1065

Authorized Official
Title or Position	:	VP REVENUE CYCLE
Name	:	KEVIN JOHANNESON
Credential	:
Telephone Number	:	423-238-7217

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	12/06/2016

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