Basic Information
| Provider Information | |||||||||
| NPI: | 1194128710 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN PHYSIATRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 658 W TREMOLO LN | ||||||||
| Address2: | |||||||||
| City: | ORO VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857373771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204713764 | ||||||||
| FaxNumber: | 5203298650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 W HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857047806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207422800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2014 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | WICK | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5204713764 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | 26973 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.