Provider Demographics
NPI:1316178783
Name:NORTHSIDE PHYSICAL THERAPY AND REHABILITATION, INC
Entity Type:Organization
Organization Name:NORTHSIDE PHYSICAL THERAPY AND REHABILITATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:386-734-1136
Mailing Address - Street 1:752 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-734-1136
Mailing Address - Fax:386-734-2262
Practice Address - Street 1:752 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3282
Practice Address - Country:US
Practice Address - Phone:386-734-1136
Practice Address - Fax:386-734-2262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-04
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLX1168AMedicare PIN