Provider Demographics
NPI:1295818748
Name:NORTHSIDE PHYSICAL THERAPY PS
Entity Type:Organization
Organization Name:NORTHSIDE PHYSICAL THERAPY PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:509-325-6776
Mailing Address - Street 1:6821 N COUNTRY HOMES BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-4372
Mailing Address - Country:US
Mailing Address - Phone:509-325-6776
Mailing Address - Fax:509-325-0817
Practice Address - Street 1:6821 N COUNTRY HOMES BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-4372
Practice Address - Country:US
Practice Address - Phone:509-325-6776
Practice Address - Fax:509-325-0817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA3797OtherRAILROAD MEDICARE
GAB37902OtherMEDICARE PROVIDER
WA7027386Medicaid
0038860OtherL & I