NPIMap

Individual provider Active NPI

Mary K Ross, DPT

  • Physical Therapist
  • Broken Bow, NE
National Provider Identifier
1760580013
Registry record updated Apr 21, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
1511 Issued in NE
Practice address
325 S 1St Ave
Broken Bow, NE 68822-2213
Phone
(308) 872-5111
Fax
(308) 872-5115
NPI assigned
Sep 20, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Apr 21, 2017

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X 1511 NE Primary

Addresses

Primary practice location

325 S 1St Ave
Broken Bow, NE 68822-2213

Mailing address

325 S 1St Ave
PO Box 435
Broken Bow, NE 68822-2213
Phone (308) 872-5111

Other identifiers 1

IdentifierTypeStateIssuer
39519OtherNEBLUE CROSS BLUE SHIELD

Other names 1

  • Mary K Blakeman Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100830001011 NE Practitioner - Physical Therapist in Private Practice 5395723134 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physical Therapist in Private Practice
Education
Other, 1996
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Team Physical Therapy PCGroup PAC ID 5991759540, 11 clinicians

Practice addresses (Care Compare)

207 S Grand Ave
Callaway, NE 68825-5199
Phone (308) 836-2288

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

Practice roles

OrganizationSpecialtyStatusNew patients
Team Physical Therapy, P.C. Physical Therapist CurrentSince Nov 15, 1996 Accepting new patients
Team Physical Therapy, P.C. CurrentSince Nov 15, 1996 Accepting new patients
Callaway Good Life Center Inc PastSince Apr 10, 2018 Accepting new patients
Team Physical Therapy, P.C. PastSince Nov 15, 1996 Accepting new patients

Locations

325 S 1st Ave
Broken Bow, NE 68822
Phone (308) 872-5111

Ownership & related parties

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Callaway District HospitalCallaway, NE, CCN 281335 Hospital Corporate Officer
Corporate Director		 Jun 1, 1998
Jun 1, 1998
Callaway District HospitalCallaway, NE, CCN 28Z335 Hospital Corporate Officer
Corporate Director		 Jun 1, 1998
Jun 1, 1998
Callaway Good Life Center IncCallaway, NE, CCN 285200 Skilled nursing facility Corporate Officer (100%) Apr 10, 2018
Callaway Medical ClinicCallaway, NE, CCN 283476 Rural health clinic Corporate Officer
Corporate Director		 Jun 1, 1998
Jun 1, 1998
Arnold Medical ClinicArnold, NE, CCN 283475 Rural health clinic Corporate Officer
Corporate Director		 Jun 1, 1998
Jun 1, 1998

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1492732800000",
    "number": "1760580013",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "325 S 1ST AVE",
            "address_2": "PO BOX 435",
            "city": "BROKEN BOW",
            "state": "NE",
            "postal_code": "688222213",
            "telephone_number": "308-872-5111",
            "fax_number": "308-872-5115"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "325 S 1ST AVE",
            "city": "BROKEN BOW",
            "state": "NE",
            "postal_code": "688222213",
            "telephone_number": "308-872-5111",
            "fax_number": "308-872-5115"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ROSS",
        "first_name": "MARY",
        "middle_name": "K",
        "credential": "DPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-09-20",
        "last_updated": "2017-04-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NE",
            "license": "1511",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "39519",
            "state": "NE"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MARY",
            "last_name": "BLAKEMAN",
            "middle_name": "K",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Broken Bow, NE

Sources for this page

Verify at the official NPI Registry.