MEDICARE: SPENCER THOMAS CUSHMAN

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	2305215852	VA
2	225100000X	Physical Therapist	PTL.0020450	CO

General Provider Information

NPI Number	:	1093490203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER THOMAS CUSHMAN

Provider Business Mailing Address
First Line	:	420 E 120TH AVE
Second Line	:
City	:	NORTHGLENN
State	:	CO
Zip	:	80233-1127
Country	:	US
Telephone Number	:	303-280-3838
Fax Number	:	303-280-3838

Provider Business Practice Location Address
First Line	:	13370 E MARY ANN CLEVELAND WAY STE 130
Second Line	:
City	:	VAIL
State	:	AZ
Zip	:	85641-8611
Country	:	US
Telephone Number	:	520-689-7144
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2023
Last Update Date	:	04/02/2025

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