Healthcare Provider Details

I. General information

NPI: 1700458643
Provider Name (Legal Business Name): TIMOTHY LOGAN IRWIN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7443 COMMONS BLVD STE 112
CHATTANOOGA TN
37421-2895
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 423-254-5461
  • Fax: 800-385-7439
Mailing address:
  • Phone: 616-356-5000
  • Fax: 616-356-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13565
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: