MEDICARE: SPORTS AND SPINE 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	261QR0400X	Rehabilitation Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DD3410	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000314395	OTHER	OH	OH BLUE CROSS/ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619923026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS AND SPINE PHYSICAL THERAPY INC

Provider Business Mailing Address
First Line	:	3355 RICHMOND RD
Second Line	:	SUITE 101A
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4100
Country	:	US
Telephone Number	:	216-593-7070
Fax Number	:

Provider Business Practice Location Address
First Line	:	3365 RICHMOND RD STE 110
Second Line	:
City	:	BEACHWOOD
State	:	OH
Zip	:	44122-4171
Country	:	US
Telephone Number	:	216-593-7070
Fax Number	:	216-593-7074

Authorized Official
Title or Position	:	REGIONAL ADMINISTRATOR
Name	:	TIFFANY MARIE WASSON
Credential	:
Telephone Number	:	216-593-7070

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	05/06/2019

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Directions to “SPORTS AND SPINE PHYSICAL THERAPY INC ” Practice Location

Language	Start Address	Practice Location

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