Provider Demographics
NPI:1265808240
Name:ORTHOSPORTS PHYSICAL THERAPY
Entity type:Organization
Organization Name:ORTHOSPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONAHUE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-989-0408
Mailing Address - Street 1:PO BOX 10837
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-0837
Mailing Address - Country:US
Mailing Address - Phone:602-989-0408
Mailing Address - Fax:623-433-8860
Practice Address - Street 1:5620 W THUNDERBIRD RD STE B1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4638
Practice Address - Country:US
Practice Address - Phone:602-989-0408
Practice Address - Fax:623-433-8860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2055261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBSJMedicare UPIN