MEDICARE: DONAHUE PHYSICAL THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5998	AZ

General Provider Information

NPI Number	:	1013057611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONAHUE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	11038 N 28TH DR APT 123
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4308
Country	:	US
Telephone Number	:	602-318-5556
Fax Number	:	602-789-6755

Provider Business Practice Location Address
First Line	:	4925 W BELL RD
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-3427
Country	:	US
Telephone Number	:	602-318-5556
Fax Number	:	602-789-6755

Authorized Official
Title or Position	:	OWNER PHYSICAL THERAPIST
Name	:	MARK CHARLES DONAHUE
Credential	:	MSPT
Telephone Number	:	602-318-5556

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	08/22/2020

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