Provider Demographics
NPI:1437343795
Name:PHYSICAL MEDICINE AND REHABILITATION, PA
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE AND REHABILITATION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT/REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COOLIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-5211
Mailing Address - Street 1:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:386-774-5251
Practice Address - Street 1:1133 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8470
Practice Address - Country:US
Practice Address - Phone:386-775-7080
Practice Address - Fax:386-775-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95874208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD02637OtherMEDICARE RAILROAD
FL278513700Medicaid
FL93047OtherBCBSFL
FLP00667019OtherMEDICARE RAILROAD
FLAG656Medicare PIN