MEDICARE: TRAVIS PHYSICAL THERAPY & SPORTS MEDICINE 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	208100000X	Physical Medicine & Rehabilitation Physician	987	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659365724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAVIS PHYSICAL THERAPY & SPORTS MEDICINE INC

Provider Business Mailing Address
First Line	:	RR 1 BOX 75-3
Second Line	:
City	:	SALEM
State	:	WV
Zip	:	26426-9604
Country	:	US
Telephone Number	:	304-782-1052
Fax Number	:	304-782-1053

Provider Business Practice Location Address
First Line	:	RR 1 BOX 75-3
Second Line	:
City	:	SALEM
State	:	WV
Zip	:	26426-9604
Country	:	US
Telephone Number	:	304-782-1052
Fax Number	:	304-782-1053

Authorized Official
Title or Position	:	PRESIDENT PHYSICAL THERAPIST
Name	:	JOHN TODD TRAVIS
Credential	:	ATC MS PT
Telephone Number	:	304-782-1052

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	09/28/2010

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