Provider Demographics
NPI:1033318027
Name:BARDITCH, GLENN (PT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BARDITCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 SW 108TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-3451
Mailing Address - Country:US
Mailing Address - Phone:305-271-9186
Mailing Address - Fax:
Practice Address - Street 1:7000 SW 62ND AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4716
Practice Address - Country:US
Practice Address - Phone:305-666-7116
Practice Address - Fax:305-665-6069
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist