Provider Demographics
NPI:1245382043
Name:FLORIDA INJURY AND REHAB
Entity Type:Organization
Organization Name:FLORIDA INJURY AND REHAB
Other - Org Name:LIVE AND LOOK GOOD WELLNESS AND WEIGHT LOSS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAUWD
Authorized Official - Middle Name:BASIYR
Authorized Official - Last Name:MEDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:407-518-7700
Mailing Address - Street 1:1520 N JOHN YOUNG PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-3219
Mailing Address - Country:US
Mailing Address - Phone:407-518-7700
Mailing Address - Fax:
Practice Address - Street 1:1520 N JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-3219
Practice Address - Country:US
Practice Address - Phone:407-518-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69749261Q00000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Not Answered261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28914OtherBLUE CROSS PROVIDER #
FLE7659WMedicare ID - Type UnspecifiedPHYSICIAN ASSISTANT
FLF67953Medicare UPIN
FLS40979Medicare UPIN
FL28914AMedicare ID - Type UnspecifiedPHYSICIAN
FLE7659WMedicare UPIN