Provider Demographics
NPI:1417208844
Name:INTEGRATIVE PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-977-3434
Mailing Address - Street 1:425 ALEXANDRIA BLVD STE 1010
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5548
Mailing Address - Country:US
Mailing Address - Phone:321-244-4644
Mailing Address - Fax:407-977-3433
Practice Address - Street 1:425 ALEXANDRIA BLVD STE 1010
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5548
Practice Address - Country:US
Practice Address - Phone:321-244-4644
Practice Address - Fax:407-977-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty