MEDICARE: ATHLETIC EDGE PHYSICAL THERAPY

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	261QR0400X	Rehabilitation Clinic/Center	10299	TN

General Provider Information

NPI Number	:	1043766975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHLETIC EDGE PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 1132
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37401-1132
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 ADAMS ST STE A
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37408
Country	:	US
Telephone Number	:	423-402-0778
Fax Number	:	186-633-4026

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	DR. BRANDON TYLER WHITWORTH
Credential	:	DPT
Telephone Number	:	631-790-9798

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	05/24/2018

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