Provider Demographics
NPI:1609063494
Name:MACCOLLOM, STUART W (PT)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:W
Last Name:MACCOLLOM
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 1:8140 BAYHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776-3321
Mailing Address - Country:US
Mailing Address - Phone:727-546-8900
Mailing Address - Fax:727-546-8940
Practice Address - Street 1:8140 BAYHAVEN DR
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-3321
Practice Address - Country:US
Practice Address - Phone:727-546-8900
Practice Address - Fax:727-546-8940
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010475500Medicaid
FLAI939YOtherMEDICARE PTAN