Provider Demographics
NPI:1275680746
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:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SERENA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-829-7712
Mailing Address - Street 1:PO BOX 64207
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728-4207
Mailing Address - Country:US
Mailing Address - Phone:520-829-7712
Mailing Address - Fax:520-314-4121
Practice Address - Street 1:10550 N LA CANADA DR
Practice Address - Street 2:STE 160
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-7130
Practice Address - Country:US
Practice Address - Phone:520-547-2476
Practice Address - Fax:520-547-2480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ825036Medicaid
AZZ25128Medicare PIN