Provider Demographics
NPI:1104836501
Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:ORTHOPEDIC & SPORTS PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:480-833-7879
Mailing Address - Street 1:1500 S DOBSON RD STE 314
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4752
Mailing Address - Country:US
Mailing Address - Phone:480-833-7879
Mailing Address - Fax:480-844-8411
Practice Address - Street 1:1500 S DOBSON RD STE 314
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4752
Practice Address - Country:US
Practice Address - Phone:480-833-7879
Practice Address - Fax:480-844-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ778,1328,52372251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ29804Medicare ID - Type UnspecifiedMEDI GROUP