Provider Demographics
NPI:1679956841
Name:SOUTHERN ADVANCED REHABILITATION CORP
Entity Type:Organization
Organization Name:SOUTHERN ADVANCED REHABILITATION CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-986-4648
Mailing Address - Street 1:10723 CORY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2725
Mailing Address - Country:US
Mailing Address - Phone:813-986-4648
Mailing Address - Fax:813-986-4648
Practice Address - Street 1:10723 CORY LAKE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2725
Practice Address - Country:US
Practice Address - Phone:813-986-4648
Practice Address - Fax:813-986-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107516208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty