Provider Demographics
NPI:1174670640
Name:ORTHOMED LLC
Entity Type:Organization
Organization Name:ORTHOMED LLC
Other - Org Name:PROACTIVE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-797-7246
Mailing Address - Street 1:PO BOX 43085
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85733-3085
Mailing Address - Country:US
Mailing Address - Phone:520-321-0204
Mailing Address - Fax:520-321-0495
Practice Address - Street 1:4570 N 1ST AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-8600
Practice Address - Country:US
Practice Address - Phone:520-321-0204
Practice Address - Fax:186-628-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5840225100000X
AZ3981225100000X
AZ4077225100000X
AZ6883225100000X
AZ3289225100000X
AZ5642225100000X
AZ1853225100000X
AZ0342225X00000X
AZ225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID NUMBER
AZZ25128Medicare PIN