Nicole    Beaulieu    RPT
Contract Details
Champion Sports Medicine--Trussville
Facility name
Provider ID
P000000101
NPI
1487803540
Tax ID
721379381
Effective Date
3/1/1999
Last Updated
2/8/2019
Direct Contract
Yes
Term Date
12/1/2018
Status
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
80.00
Location Details
Address
7270 Gadsden Highway Suite 108
Trussville, AL 35173
United States
County
Jefferson
Phone
2056557231 (Phone)
Billing Details
Address
P.O. Box 1245
Indiana, PA 15701
Billing Phone
7244653496
Specialty Type
Physical Therapy
Map
Address