Provider Demographics
NPI:1366441057
Name:VLASICH, MICHAEL G (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:VLASICH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4699 SE WINTER HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-8579
Mailing Address - Country:US
Mailing Address - Phone:772-286-6654
Mailing Address - Fax:772-286-6654
Practice Address - Street 1:4699 SE WINTER HAVEN CT
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-8579
Practice Address - Country:US
Practice Address - Phone:772-286-6654
Practice Address - Fax:772-286-6654
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 13615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY051BZMedicare ID - Type UnspecifiedPHYSICAL THERAPIST