Basic Information
| Provider Information | |||||||||
| NPI: | 1528199254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SITKA PHYSICAL THERAPY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 700 KATLIAN ST STE E | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077475861 | ||||||||
| FaxNumber: | 9077475415 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 KATLIAN ST STE E | ||||||||
| Address2: | |||||||||
| City: | SITKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998357359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077475861 | ||||||||
| FaxNumber: | 9077475415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPECK | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9077475861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | 306628 | AK | N | Suppliers | Prosthetic/Orthotic Supplier | 261QP2000X | 306628 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | PT7699 | 05 | AK | MEDICAID |