Evan Blackburn, P.T.
Individual provider Active NPI Physical Therapist · Suwanee, GA
NPI 1154437754 · NPPES record last updated Nov 22, 2013
Key facts
- NPI
- 1154437754
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physical Therapist 225100000X
- License
- PT005107 (GA)
- Practice address
- 1180 Satellite Blvd NW
Suite 100
Suwanee, GA 30024-4636 - Phone
- (404) 367-2080
- Fax
- (770) 495-3493
- NPI assigned
- Aug 23, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Medicare Care Compare profile
- Specialty
- Physical Therapist in Private Practice
- Education
- Cleveland University of Medicine and Surgery - NLG, 1990
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Athletes in Motion LLC
Practice addresses (Care Compare)
1180 Satellite Blvd NW
Suite 100
Suwanee, GA 30024-4637
Phone (404) 367-2080
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20080116000457 | GA | Practitioner - Physical Therapist in Private Practice | 3779565163 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT005107 | GA | MD | Physical Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Advance Rehabilitation & Consulting Limited Partnership | Physical Therapist | Current |
Accepting new patients |
| Advance Rehabilitation & Consulting Limited Partnership | Physical Therapist | Current |
Accepting new patients |
| Athletes in Motion LLC | Current |
Accepting new patients | |
| High Performance Physical Therapy Centers | Physical Therapist | Past | Accepting new patients |
Locations
7423 Adairsville Hwy
Adairsville, GA 30103
Phone (770) 373-9315
3511 Braselton Hwy
Ste G2
Dacula, GA 30019
Phone (404) 367-2082
1000 Johnson Ferry Rd
Ste A115
Marietta, GA 30068
Phone (404) 367-2085
1180 Satellite Blvd NW
Ste 100
Suwanee, GA 30024
Phone (404) 367-2080
1180 Satellite Blvd NW
Ste 10
Suwanee, GA 30024
Phone (404) 367-2080
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | |||
| Physical Therapist | 225100000X | PT005107 | GA | Yes |
Addresses
Primary practice location
1180 Satellite Blvd NW
Suite 100
Suwanee, GA 30024-4636
Mailing address
1180 Satellite Blvd NW
Suite 100
Suwanee, GA 30024-4636
Phone (404) 367-2080
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 005107 | Other | GA | LICENSE # |
Other providers in Suwanee, GA
- Joanne Bien-Aime
- Billy Adams, LPC, LLC
- Ellen Biros
- Brantley Black Bruce
- Lisa Black
- Brittany Bledsoe
- Blossom Pediatric Dentistry, LLC
- Blpodiatry LLC
- Emily Blum
- Emily Rose Bolt
All providers in Suwanee, GA · Physical Therapist in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 22, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.