Basic Information
| Provider Information | |||||||||
| NPI: | 1881697597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADDICOTT | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | COREY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 20325 N 51ST AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853084622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023852115 | ||||||||
| FaxNumber: | 4804183323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 5198 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 5198 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | 5198 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
ID Information
| ID | Type | State | Issuer | Description | 113252 | 05 | AZ | MEDICAID | 69799 | 01 | AZ | MEDICARE | OTHER |