Provider Demographics
NPI:1871591875
Name:DERSCHEID, GARY L (PT, ATC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:DERSCHEID
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5749
Mailing Address - Country:US
Mailing Address - Phone:480-596-6999
Mailing Address - Fax:480-596-9555
Practice Address - Street 1:5320 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5749
Practice Address - Country:US
Practice Address - Phone:480-596-6999
Practice Address - Fax:480-596-9555
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ26468Medicare ID - Type UnspecifiedMEDICARE ID
AZS75341Medicare UPIN