MEDICARE: INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QM1300X	Multi-Specialty Clinic/Center
2	261QX0100X	Occupational Medicine Clinic/Center
3	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1265872287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT PHYSICAL THERAPY OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	8823 PRODUCTION LN
Second Line	:
City	:	OOLTEWAH
State	:	TN
Zip	:	37363-6511
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:	423-238-3473

Provider Business Practice Location Address
First Line	:	842 N HIGHLAND AVE NE STE TER
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-4530
Country	:	US
Telephone Number	:	678-685-9356
Fax Number	:	678-685-9357

Authorized Official
Title or Position	:	MANAGER
Name	:	KILEY RUSSELL
Credential	:
Telephone Number	:	423-238-7217

Provider Enumeration Date	:	07/05/2013
Last Update Date	:	07/05/2013

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