MEDICARE: PHYSICALLY CORRECT PHYSICAL THERAPY SERVICES, 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	246Z00000X	Other Specialist/Technologist	5058-024	WI

General Provider Information

NPI Number	:	1710323563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICALLY CORRECT PHYSICAL THERAPY SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 370081
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53237-1181
Country	:	US
Telephone Number	:	414-940-7278
Fax Number	:	414-235-4884

Provider Business Practice Location Address
First Line	:	5889 RIVERSIDE DR
Second Line	:
City	:	GREENDALE
State	:	WI
Zip	:	53129-2817
Country	:	US
Telephone Number	:	414-940-7278
Fax Number	:	414-235-4884

Authorized Official
Title or Position	:	OWNER
Name	:	MR. PHILIP WILLIAM BERGOLD
Credential	:	PT
Telephone Number	:	414-940-7278

Provider Enumeration Date	:	05/21/2013
Last Update Date	:	05/21/2013

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