MEDICARE: POLARIS PHYSICAL THERAPY P.C.

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	2251X0800X	Orthopedic Physical Therapist	3974	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0299910	OTHER	AZ	BCBS OF ARIZONA

General Provider Information

NPI Number	:	1184628562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLARIS PHYSICAL THERAPY P.C.

Provider Business Mailing Address
First Line	:	2404 E RIVER ROAD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718
Country	:	US
Telephone Number	:	520-408-9868
Fax Number	:	520-300-7020

Provider Business Practice Location Address
First Line	:	2404 E RIVER ROAD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718
Country	:	US
Telephone Number	:	520-408-9868
Fax Number	:	520-300-7020

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW LINCOLN SPARROW
Credential	:	M.P.T.
Telephone Number	:	520-408-9868

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	07/24/2014

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