Provider Demographics
NPI:1235483793
Name:GREEN, ERIC L (PTA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3334 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8405
Mailing Address - Country:US
Mailing Address - Phone:850-877-8855
Mailing Address - Fax:859-877-7627
Practice Address - Street 1:257 SW DADE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-2361
Practice Address - Country:US
Practice Address - Phone:850-973-3316
Practice Address - Fax:850-973-1261
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPTA23651225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106822Medicare PIN