=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528364221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMIE'S PHYSICAL THERAPY AND SPORTS MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2011
-----------------------------------------------------
Last Update Date | 03/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2284 BROADHEAD ROAD
-----------------------------------------------------
City | ALIQUIPPA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15001-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-788-1770
-----------------------------------------------------
Fax | 724-788-1994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2284 BROADHEAD ROAD
-----------------------------------------------------
City | ALIQUIPPA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15001-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-788-1770
-----------------------------------------------------
Fax | 724-788-1994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JAMES G YOUNG
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 724-788-1770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | PT010361L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT010361L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------