MEDICARE: EDGEBROOK PHYSICAL THERAPY, 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	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1477923886
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEBROOK PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	PO BOX 150
Second Line	:
City	:	LIMA
State	:	OH
Zip	:	45802-0150
Country	:	US
Telephone Number	:	419-221-6717
Fax Number	:	419-222-0507

Provider Business Practice Location Address
First Line	:	1643 N ALPINE RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-1462
Country	:	US
Telephone Number	:	815-289-6942
Fax Number	:	815-547-1024

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MR. STEPHEN KRZYMINSKI
Credential	:
Telephone Number	:	419-221-6717

Provider Enumeration Date	:	09/28/2015
Last Update Date	:	09/28/2023

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