MEDICARE: SUPREME PHYSICAL THERAPY, INC.

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	225100000X	Physical Therapist	4097	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	349G0SU	OTHER	MN	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1255303095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	5201 CHOWEN AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-2121
Country	:	US
Telephone Number	:	612-805-2741
Fax Number	:

Provider Business Practice Location Address
First Line	:	5201 CHOWEN AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55410-2121
Country	:	US
Telephone Number	:	612-805-2741
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN MARY PRIEM
Credential	:	PHYSICAL THERAPIST
Telephone Number	:	612-805-2741

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	08/22/2020

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