Provider Demographics
NPI:1376557090
Name:FAIRWAY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FAIRWAY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHUMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-685-2492
Mailing Address - Street 1:7100 FAIRWAY DR STE 42
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-3778
Mailing Address - Country:US
Mailing Address - Phone:561-775-7775
Mailing Address - Fax:561-293-2730
Practice Address - Street 1:7100 FAIRWAY DR STE 42
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-3778
Practice Address - Country:US
Practice Address - Phone:561-775-7775
Practice Address - Fax:561-932-2730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY915MOtherBCBS OF FL
K6257Medicare UPIN
FLK6257Medicare PIN