Provider Demographics
NPI:1104979855
Name:ANDREASEN PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:ANDREASEN PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDREASEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-201-0877
Mailing Address - Street 1:1808 N 2190 E
Mailing Address - Street 2:
Mailing Address - City:SUGAR CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83448-1310
Mailing Address - Country:US
Mailing Address - Phone:208-201-0877
Mailing Address - Fax:
Practice Address - Street 1:1808 N 2190 E
Practice Address - Street 2:
Practice Address - City:SUGAR CITY
Practice Address - State:ID
Practice Address - Zip Code:83448-1310
Practice Address - Country:US
Practice Address - Phone:208-201-0877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-737225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID327268OtherBLUE SHIELD NUMBER
IDT3761OtherBLUE CROSS NUMBER
IDT3761OtherBLUE CROSS NUMBER