Provider Demographics
NPI:1912063512
Name:AXIS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:AXIS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-542-3333
Mailing Address - Street 1:420 N HIGGINS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4524
Mailing Address - Country:US
Mailing Address - Phone:406-542-3333
Mailing Address - Fax:406-542-3365
Practice Address - Street 1:420 N HIGGINS AVE STE B
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4524
Practice Address - Country:US
Practice Address - Phone:406-542-3333
Practice Address - Fax:406-542-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1679PT225100000X
MT1517PT225100000X
MT1585PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000061378OtherBLUE CROSS OF MONTANA
MT000061378OtherBLUE CROSS OF MONTANA