Provider Demographics
NPI:1659431641
Name:PHYSIO MED OF ORLANDO
Entity Type:Organization
Organization Name:PHYSIO MED OF ORLANDO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLEM
Authorized Official - Middle Name:G
Authorized Official - Last Name:VAN DE WOUW
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:407-363-3443
Mailing Address - Street 1:8853 COMMODITY CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9010
Mailing Address - Country:US
Mailing Address - Phone:407-363-3443
Mailing Address - Fax:407-363-9446
Practice Address - Street 1:8853 COMMODITY CIR STE 1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9010
Practice Address - Country:US
Practice Address - Phone:407-363-3443
Practice Address - Fax:407-363-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686652Medicare ID - Type UnspecifiedMEDICARE