Basic Information
| Provider Information | |||||||||
| NPI: | 1750454104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCCALL PHYSICAL THERAPY, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 E PARK ST | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086343555 | ||||||||
| FaxNumber: | 2086348793 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 E PARK ST | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086343555 | ||||||||
| FaxNumber: | 2086348793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | BAILEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2086343555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 06155 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | TA872 | 01 | ID | BLUE CROSS | OTHER |