NPIMap

Organization Active NPI

Andersen Physical Therapy, Inc

  • Physical Therapist
  • Modesto, CA
National Provider Identifier
1225029630
Registry record updated Apr 17, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
ANDERSEN PHYSICAL THERAPY, INC
Practice address
1917 Coffee Rd
Modesto, CA 95355-2704
Phone
(209) 549-4626
Fax
(209) 549-4625
NPI assigned
Nov 3, 2005
Last updated
Apr 17, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 17, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lyle Melvin Andersen, PTNPI 1265413918
Title
Co Owner
Phone
(209) 549-4626

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X NU Primary
Occupational Therapist 225X00000X NU
Physical Therapy Clinic/Center 261QP2000X NU
Physical Therapy Clinic/Center 261QP2000X 0134075 CA

Addresses

Primary practice location

1917 Coffee Rd
Modesto, CA 95355-2704

Mailing address

PO Box 576276
Modesto, CA 95357-6276
Phone (209) 549-4626

Other identifiers 1

IdentifierTypeStateIssuer
YYY48495YOtherCABLUE SHIELD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050610000843 CA Part B Supplier - Physical/Occupational Therapy Group in Private Practice 3678520244 Receives reassigned benefits from 13 practitioners
2 other NPIs on this enrollment
Practice locations: Modesto, CA; Oakdale, CA; Stockton, CA; Turlock, CA
O20100930016155 CA DME Supplier - Independently-Practicing Physical TherapistDME Supplier - Independently-Practicing Occupational Therapist 3678520244 Practice locations: Modesto, CA

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Andersen Physical Therapy Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1917 Coffee Rd
Modesto, CA 95355
Phone (209) 549-4626

8807 Thornton Rd
Stockton, CA 95209
Phone (209) 473-3221

8807 Thornton Rd
Ste M
Stockton, CA 95209
Phone (209) 549-4626

4230 N Golden State Blvd
Turlock, CA 95382
Phone (209) 549-4626

Ownership & related parties

Subparts reporting this organization as parent 2

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1130976000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1492387200000",
    "number": "1225029630",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 576276",
            "city": "MODESTO",
            "state": "CA",
            "postal_code": "953576276",
            "telephone_number": "209-549-4626",
            "fax_number": "209-549-4625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1917 COFFEE RD",
            "city": "MODESTO",
            "state": "CA",
            "postal_code": "953552704",
            "telephone_number": "209-549-4626",
            "fax_number": "209-549-4625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ANDERSEN PHYSICAL THERAPY, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-11-03",
        "last_updated": "2017-04-17",
        "status": "A",
        "authorized_official_last_name": "ANDERSEN",
        "authorized_official_first_name": "LYLE",
        "authorized_official_middle_name": "MELVIN",
        "authorized_official_title_or_position": "CO OWNER",
        "authorized_official_telephone_number": "209-549-4626",
        "authorized_official_credential": "PT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "CA",
            "license": "0134075",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "YYY48495Y",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Modesto, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.