Provider Demographics
NPI:1023579554
Name:FIDALGO FUNCTIONAL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:FIDALGO FUNCTIONAL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MCPHEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:360-588-8075
Mailing Address - Street 1:1813 O AVE
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2344
Mailing Address - Country:US
Mailing Address - Phone:360-588-8705
Mailing Address - Fax:360-588-0406
Practice Address - Street 1:1813 O AVE
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2344
Practice Address - Country:US
Practice Address - Phone:360-588-8705
Practice Address - Fax:360-588-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2070154Medicaid