Provider Demographics
NPI:1881697597
Name:ADDICOTT, ROBERT COREY (PT)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:COREY
Last Name:ADDICOTT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:20325 N 51ST AVE STE 150
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4622
Practice Address - Country:US
Practice Address - Phone:602-385-2115
Practice Address - Fax:480-418-3323
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51982251X0800X, 225100000X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113252Medicaid
AZ69799OtherMEDICARE