Basic Information
| Provider Information | |||||||||
| NPI: | 1780651158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL THERAPY COMPLETE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 E VIRGINIA AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022645323 | ||||||||
| FaxNumber: | 6022645302 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 E VIRGINIA AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022645323 | ||||||||
| FaxNumber: | 6022645302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | GLEASON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 6022645323 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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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 | 2Z1876 | 01 | AZ | HEALTHNET PROVIDER ID | OTHER | 8145185 | 01 | AZ | AETNA PROVIDER ID | OTHER | 854184 | 05 | AZ | MEDICAID | P0460470 | 01 | AZ | BCBS OF ARIZONA | OTHER |