Provider Demographics
NPI:1740529536
Name:PHYSICAL MEDICINE OF ARIZONA, LLC
Entity type:Organization
Organization Name:PHYSICAL MEDICINE OF ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:HIRST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-822-7638
Mailing Address - Street 1:422 E HAROLD DR
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-5689
Mailing Address - Country:US
Mailing Address - Phone:480-822-7638
Mailing Address - Fax:
Practice Address - Street 1:2181 E PECOS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-6140
Practice Address - Country:US
Practice Address - Phone:480-822-7638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207Q00000X, 207QS0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty