Provider Demographics
NPI:1346505559
Name:PHYSICAL THERAPY AT HOME INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AT HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GOMAA
Authorized Official - Middle Name:RAMADAM
Authorized Official - Last Name:IBRAHIM ALI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:941-206-5200
Mailing Address - Street 1:611 MAY APPLE WAY
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-7278
Mailing Address - Country:US
Mailing Address - Phone:941-206-5200
Mailing Address - Fax:941-504-6842
Practice Address - Street 1:1121 JACARANDA BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4586
Practice Address - Country:US
Practice Address - Phone:941-206-5200
Practice Address - Fax:941-504-6842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12658225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGN735ZMedicare UPIN