Provider Demographics
NPI:1225226632
Name:PAN ALASKA PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PAN ALASKA PHYSICAL THERAPY
Other - Org Name:EAGLE CENTER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-696-5678
Mailing Address - Street 1:11470 BUSINESS BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7721
Mailing Address - Country:US
Mailing Address - Phone:907-696-5678
Mailing Address - Fax:
Practice Address - Street 1:11470 BUSINESS BLVD # 200
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7721
Practice Address - Country:US
Practice Address - Phone:907-696-5678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAN ALASKA PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK167831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK0000WCKCPMedicare PIN