Provider Demographics
NPI:1689058125
Name:ADVANCED PHYSICAL MEDICINE & REHAB
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL MEDICINE & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GLOYDIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ-GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-748-4742
Mailing Address - Street 1:2835 ALT 19
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1926
Mailing Address - Country:US
Mailing Address - Phone:727-748-4742
Mailing Address - Fax:727-748-4739
Practice Address - Street 1:2835 ALT 19
Practice Address - Street 2:SUITE B
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1926
Practice Address - Country:US
Practice Address - Phone:727-748-4742
Practice Address - Fax:727-748-4739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110430208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1336320787OtherNPI