MEDICARE: ANDREASEN PHYSICAL THERAPY PC

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	PT-737	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	327268	OTHER	ID	BLUE SHIELD NUMBER
2	T3761	OTHER	ID	BLUE CROSS NUMBER

General Provider Information

NPI Number	:	1104979855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREASEN PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	1808 N 2190 E
Second Line	:
City	:	SUGAR CITY
State	:	ID
Zip	:	83448-1310
Country	:	US
Telephone Number	:	208-201-0877
Fax Number	:

Provider Business Practice Location Address
First Line	:	1808 N 2190 E
Second Line	:
City	:	SUGAR CITY
State	:	ID
Zip	:	83448-1310
Country	:	US
Telephone Number	:	208-201-0877
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DIRK ANDREASEN
Credential	:	PT
Telephone Number	:	208-201-0877

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	08/22/2020

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