Healthcare Provider Details

I. General information

NPI: 1295827384
Provider Name (Legal Business Name): SOUTHWEST SPORTS MEDICINE & ORTHOPAEDIC SURGERY CLINIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8580 E SHEA BLVD
SCOTTSDALE AZ
85260-6685
US

IV. Provider business mailing address

8580 E SHEA BLVD STE 120
SCOTTSDALE AZ
85260-6684
US

V. Phone/Fax

Practice location:
  • Phone: 480-763-5950
  • Fax: 480-763-1375
Mailing address:
  • Phone: 480-763-5950
  • Fax: 480-763-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELO J MATTALINO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 480-763-5950