Basic Information
| Provider Information | |||||||||
| NPI: | 1932131455 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEAK PHYSICAL THERAPY & SPORTS MEDICINE OF WYLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W BROWN ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | WYLIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750985816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724425287 | ||||||||
| FaxNumber: | 9724423181 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W BROWN ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | WYLIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750985816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724425287 | ||||||||
| FaxNumber: | 9724423181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 12/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | BROAD | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | RICHARD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR/THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9724425287 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1152490 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0021MJ | 01 | TX | BCBS GROUP # | OTHER | DD3715 | 01 | TX | MEDICARE RAILROAD GROUP # | OTHER |