Provider Demographics
NPI:1184628562
Name:POLARIS PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:POLARIS PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:LINCOLN
Authorized Official - Last Name:SPARROW
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:520-408-9868
Mailing Address - Street 1:2404 E RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718
Mailing Address - Country:US
Mailing Address - Phone:520-408-9868
Mailing Address - Fax:520-300-7020
Practice Address - Street 1:2404 E RIVER ROAD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718
Practice Address - Country:US
Practice Address - Phone:520-408-9868
Practice Address - Fax:520-300-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ39742251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0299910OtherBCBS OF ARIZONA
AZ26852Medicare ID - Type UnspecifiedGROUP ID