Basic Information
| Provider Information | |||||||||
| NPI: | 1174563357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | FORDYCE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | BILL | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763800 | ||||||||
| FaxNumber: | 6238763975 | ||||||||
| Practice Location | |||||||||
| Address1: | 13760 N 93RD AVE | ||||||||
| Address2: | STE 107 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763952 | ||||||||
| FaxNumber: | 6238763975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5386 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 931726 | 05 | AZ | MEDICAID |