Provider Demographics
NPI:1184613523
Name:TRI-STATE PHYSICAL THERAPY SERVICES INC
Entity type:Organization
Organization Name:TRI-STATE PHYSICAL THERAPY SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BHANU
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-754-0700
Mailing Address - Street 1:1788 HIGHWAY 95
Mailing Address - Street 2:#14
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6074
Mailing Address - Country:US
Mailing Address - Phone:928-758-1007
Mailing Address - Fax:928-758-2544
Practice Address - Street 1:1788 HIGHWAY 95
Practice Address - Street 2:#14
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6074
Practice Address - Country:US
Practice Address - Phone:928-758-1007
Practice Address - Fax:928-758-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0463070OtherBCBS
AZP00154262OtherRAILROAD MEDICARE
AZ2Z1029OtherHEALTH NET
AZ7880871OtherAETNA
AZ696683OtherUNITED HEALTH CARE
AZ792201Medicaid
AZZ101764Medicare ID - Type Unspecified