MEDICARE: ORTHOSPORT PHYSICAL THERAPY, LLC

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		SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7620	OTHER	SC	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1639346547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOSPORT PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	95 MATHEWS DR STE D5
Second Line	:
City	:	HILTON HEAD
State	:	SC
Zip	:	29926-3768
Country	:	US
Telephone Number	:	843-681-5640
Fax Number	:	843-681-5631

Provider Business Practice Location Address
First Line	:	95 MATHEWS DR STE D5
Second Line	:
City	:	HILTON HEAD
State	:	SC
Zip	:	29926-3768
Country	:	US
Telephone Number	:	843-681-5640
Fax Number	:	843-681-5631

Authorized Official
Title or Position	:	OWNER
Name	:	JEFF FROMDAHL
Credential	:	MSPT
Telephone Number	:	843-681-5640

Provider Enumeration Date	:	05/09/2008
Last Update Date	:	05/09/2008

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