Provider Demographics
NPI:1043637861
Name:INTEGRATIVE PHYSICAL MEDICINE OF LAKE MARY LLC
Entity Type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE OF LAKE MARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-792-0705
Mailing Address - Street 1:1343 S INTERNATIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1401
Mailing Address - Country:US
Mailing Address - Phone:407-792-0705
Mailing Address - Fax:407-792-0710
Practice Address - Street 1:1343 S INTERNATIONAL PKWY
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-1401
Practice Address - Country:US
Practice Address - Phone:407-792-0705
Practice Address - Fax:407-792-0710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE PHYSICAL MEDICINE HOLDING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-19
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GV478AMedicare PIN
6726960001Medicare NSC