Basic Information
Provider Information | |||||||||
NPI: | 1295818748 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHSIDE PHYSICAL THERAPY PS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6821 N COUNTRY HOMES BLVD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992084372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093256776 | ||||||||
FaxNumber: | 5093250817 | ||||||||
Practice Location | |||||||||
Address1: | 6821 N COUNTRY HOMES BLVD | ||||||||
Address2: | SUITE 102 | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992084372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5093256776 | ||||||||
FaxNumber: | 5093250817 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 03/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PETERSON | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER PT | ||||||||
AuthorizedOfficialTelephone: | 5093256776 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | DA3797 | 01 |   | RAILROAD MEDICARE | OTHER | GAB37902 | 01 |   | MEDICARE PROVIDER | OTHER | 7027386 | 05 | WA |   | MEDICAID | 0038860 | 01 |   | L & I | OTHER |