Provider Demographics
NPI:1073610440
Name:NORTHWEST ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:NORTHWEST ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:623-556-5013
Mailing Address - Street 1:14800 W MOUNTAIN VIEW BLVD STE 260
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4797
Mailing Address - Country:US
Mailing Address - Phone:623-556-5013
Mailing Address - Fax:623-556-9290
Practice Address - Street 1:14800 W MOUNTAIN VIEW BLVD STE 260
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4797
Practice Address - Country:US
Practice Address - Phone:623-556-5013
Practice Address - Fax:623-556-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDF2066OtherRAILROAD MEDICARE
AZDF2066OtherRAILROAD MEDICARE