Provider Demographics
NPI:1417957358
Name:PALM HARBOR PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PALM HARBOR PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:N
Authorized Official - Last Name:LOSCALZO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, ATC
Authorized Official - Phone:727-789-6008
Mailing Address - Street 1:30522 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-4444
Mailing Address - Country:US
Mailing Address - Phone:727-789-6008
Mailing Address - Fax:727-789-0716
Practice Address - Street 1:30522 US HIGHWAY 19 N
Practice Address - Street 2:SUITE 110
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-4444
Practice Address - Country:US
Practice Address - Phone:727-789-6008
Practice Address - Fax:727-789-0716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT4811225100000X
FLSA2119235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR3LOtherB/C B/S PROV# - PH OFFICE
FL882119400Medicaid
FLRA4OtherBCBS PROV# - NPR OFFICE
FL106801Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER