NPIMap

Organization Active NPI

Protailored Physical Therapy LLC

  • Orthopedic Physical Therapist
  • Fort Wayne, IN
National Provider Identifier
1063805042
Registry record updated Jun 1, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Orthopedic Physical TherapistTaxonomy code 2251X0800X
License
05011654A Issued in IN
Legal business name
PROTAILORED PHYSICAL THERAPY LLC
Practice address
12722 Tonkel Rd Ste 102
Fort Wayne, IN 46845-8201
Phone
(260) 739-0300
Fax
(260) 818-2299
NPI assigned
Mar 14, 2015
Last updated
Jun 1, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 1, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jonathan T Evans, PT, DPTNPI 1033493622
Title
Physical Therapist/Owner
Phone
(260) 570-8239

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Orthopedic Physical Therapist 2251X0800X 05011654A IN Primary

Addresses

Primary practice location

12722 Tonkel Rd Ste 102
Fort Wayne, IN 46845-8201

Mailing address

12722 Tonkel Rd Ste 102
Fort Wayne, IN 46845-8201
Phone (260) 739-0300

Other identifiers 1

IdentifierTypeStateIssuer
201289250AMedicaidIN

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL www.protailored.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150421000554 IN Part B Supplier - Physical/Occupational Therapy Group in Private Practice 4385962497 Receives reassigned benefits from 24 practitioners
Practice locations: Fort Wayne, IN

National Provider Directory

National Provider Directory

Locations

12722 Tonkel Rd
Ste 102
Fort Wayne, IN 46845
Phone (260) 739-0300

12912 Coldwater Rd
Ste 9B
Fort Wayne, IN 46845
Phone (260) 570-8239

14413 Illinois Rd
Ste D
Fort Wayne, IN 46814
Phone (260) 739-0300

1520 N Hill Dr
Fort Wayne, IN 46825
Phone (260) 739-0300

3730 Maplecrest Rd
Fort Wayne, IN 46815
Phone (260) 739-0300

4011 W Jefferson Blvd
Ste 175
Fort Wayne, IN 46804
Phone (260) 436-4438

4011 W Jefferson Blvd
Ste 200
Fort Wayne, IN 46804
Phone (260) 739-0300

Practitioners & affiliated clinicians

Practitioners 28

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 28

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1426291200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1590969600000",
    "number": "1063805042",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12722 TONKEL RD STE 102",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468458201",
            "telephone_number": "260-739-0300",
            "fax_number": "260-818-2299"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12722 TONKEL RD STE 102",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468458201",
            "telephone_number": "260-739-0300",
            "fax_number": "260-818-2299"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROTAILORED PHYSICAL THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-03-14",
        "last_updated": "2020-06-01",
        "certification_date": "2020-06-01",
        "status": "A",
        "authorized_official_last_name": "EVANS",
        "authorized_official_first_name": "JONATHAN",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "PHYSICAL THERAPIST/OWNER",
        "authorized_official_telephone_number": "260-570-8239",
        "authorized_official_credential": "PT, DPT"
    },
    "taxonomies": [
        {
            "code": "2251X0800X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Orthopedic",
            "state": "IN",
            "license": "05011654A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201289250A",
            "state": "IN"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "www.protailored.com",
            "affiliation": "N",
            "address_1": "12722 Tonkel Rd Ste 102",
            "city": "Fort Wayne",
            "state": "IN",
            "country_code": "US",
            "postal_code": "468458201",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.