Healthcare Provider Details

I. General information

NPI: 1104836501
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S DOBSON RD STE 314
MESA AZ
85202-4752
US

IV. Provider business mailing address

1500 S DOBSON RD STE 314
MESA AZ
85202-4752
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-7879
  • Fax: 480-844-8411
Mailing address:
  • Phone: 480-833-7879
  • Fax: 480-844-8411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number778,1328,5237
License Number StateAZ

VIII. Authorized Official

Name: R SAMUEL ANDERSON
Title or Position: OWNER, PRESIDENT
Credential: PT, DPT, OCS
Phone: 480-833-7879