MEDICARE: PERFORMANCE PHYSICAL THERAPY, PC

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	060833	OTHER	MT	BCBS

General Provider Information

NPI Number	:	1043259724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERFORMANCE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	825 SAGEBRUSH LN STE 1
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-2320
Country	:	US
Telephone Number	:	406-846-7770
Fax Number	:	406-846-7771

Provider Business Practice Location Address
First Line	:	600 MAIN ST
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-1440
Country	:	US
Telephone Number	:	406-846-7770
Fax Number	:	406-846-7771

Authorized Official
Title or Position	:	PRESIDENT PHYSICAL THERAPIST
Name	:	MR. ERIC SHANE SPEARS
Credential	:	MPT
Telephone Number	:	406-846-7770

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	08/16/2019

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