NPIMap

Organization Active NPI

Eagle Rock Physical Therapy PLLC

  • Physical Therapy Clinic/Center
  • Idaho Falls, ID
National Provider Identifier
1174712418
Registry record updated Apr 19, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
License
PT-2217 Issued in ID
Legal business name
EAGLE ROCK PHYSICAL THERAPY PLLC
Practice address
1510 Elk Creek Dr
Idaho Falls, ID 83404-8322
Phone
(208) 522-7627
Fax
(208) 524-6300
NPI assigned
Oct 23, 2007
Last updated
Apr 19, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 19, 2021

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

Authorized official

Name
Dr. Jacob Benjamin Roberts, DPTNPI 1790989945
Title
Physical Therapist
Phone
(208) 521-7336

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
Physical Therapy Clinic/Center 261QP2000X PT-2217 ID Primary

Addresses

Primary practice location

1510 Elk Creek Dr
Idaho Falls, ID 83404-8322

Mailing address

1510 Elk Creek Dr
Idaho Falls, ID 83404-8322
Phone (208) 522-7627

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20071101000339 ID Part B Supplier - Clinic/Group Practice 0941397343 Receives reassigned benefits from 4 practitioners
Practice locations: Idaho Falls, ID; Rexburg, ID

National Provider Directory

National Provider Directory
Tax ID family
Eagle Rock Physical Therapy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1510 Elk Creek Dr
Idaho Falls, ID 83404
Phone (208) 522-7627

Practitioners & affiliated clinicians

Practitioners 12

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.

NPI Registry JSON

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

{
    "created_epoch": "1193097600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1618790400000",
    "number": "1174712418",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1510 ELK CREEK DR",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834048322",
            "telephone_number": "208-522-7627",
            "fax_number": "208-524-6300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1510 ELK CREEK DR",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834048322",
            "telephone_number": "208-522-7627",
            "fax_number": "208-524-6300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE ROCK PHYSICAL THERAPY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-23",
        "last_updated": "2021-04-19",
        "certification_date": "2021-04-19",
        "status": "A",
        "authorized_official_last_name": "ROBERTS",
        "authorized_official_first_name": "JACOB",
        "authorized_official_middle_name": "BENJAMIN",
        "authorized_official_title_or_position": "PHYSICAL THERAPIST",
        "authorized_official_telephone_number": "208-521-7336",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPT"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "ID",
            "license": "PT-2217",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2021; 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.