Provider Demographics
NPI:1679811970
Name:UNIVERSITY PHYSICAL MEDICINE INC
Entity Type:Organization
Organization Name:UNIVERSITY PHYSICAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLETTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-576-2129
Mailing Address - Street 1:1224 OCALA RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32304-1548
Mailing Address - Country:US
Mailing Address - Phone:850-576-2129
Mailing Address - Fax:850-576-9602
Practice Address - Street 1:1224 OCALA RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32304-1548
Practice Address - Country:US
Practice Address - Phone:850-576-2129
Practice Address - Fax:850-576-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-21
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 57039208D00000X
FLRN 2567282208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty