MEDICARE: SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, LLC

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	11-02934	KS
2	225100000X	Physical Therapist	24-00361	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	115683	OTHER	KS	BCBS GROUP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396844874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST KANSAS ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 14
Second Line	:
City	:	FORT SCOTT
State	:	KS
Zip	:	66701-0014
Country	:	US
Telephone Number	:	620-223-4555
Fax Number	:

Provider Business Practice Location Address
First Line	:	1623 S MAIN ST
Second Line	:
City	:	FORT SCOTT
State	:	KS
Zip	:	66701-2656
Country	:	US
Telephone Number	:	620-223-4555
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WILLIAM B. ALLEN
Credential	:	PT
Telephone Number	:	620-223-4555

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/24/2025

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