Healthcare Provider Details

I. General information

NPI: 1023028834
Provider Name (Legal Business Name): CROSSROADS ORTHOPEDIC SUBSPECIALISTS, LLC DBA CROSSROADS PHYSICAL THER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 PARKWAY S SUITE 202
WATERFORD CT
06385-1234
US

IV. Provider business mailing address

8259 WICKER AVE
SAINT JOHN IN
46373-8878
US

V. Phone/Fax

Practice location:
  • Phone: 860-447-2193
  • Fax:
Mailing address:
  • Phone: 219-365-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREG COOPER
Title or Position: MANAGING PARTNER
Credential:
Phone: 219-365-6560