Provider Demographics
NPI:1487670550
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BASTEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:480-706-1161
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1116
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6691
Practice Address - Country:US
Practice Address - Phone:480-706-1161
Practice Address - Fax:480-706-7997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2021-07-13
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
AZ=========OtherTIN
AZ4916940001Medicare NSC