Provider Demographics
NPI:1578673562
Name:PETERSEN PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:PETERSEN PHYSICAL THERAPY PC
Other - Org Name:INGLISH AND PETERSEN PHYSICAL THERAPY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WACHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-833-1005
Mailing Address - Street 1:1844 E BASELINE RD STE C5
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1506
Mailing Address - Country:US
Mailing Address - Phone:480-833-1005
Mailing Address - Fax:480-833-1312
Practice Address - Street 1:1844 E BASELINE RD STE C5
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1506
Practice Address - Country:US
Practice Address - Phone:480-833-1005
Practice Address - Fax:480-833-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
AZ261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0293570OtherBC/BS
AZ930249Medicaid
AZ930249Medicaid
AZZ102616Medicare PIN