Provider Demographics
NPI:1689774838
Name:REHABILITATION MEDICAL GRP PA
Entity Type:Organization
Organization Name:REHABILITATION MEDICAL GRP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-649-8707
Mailing Address - Street 1:100 WEST GORE STREET STE 203
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1041
Mailing Address - Country:US
Mailing Address - Phone:407-649-8707
Mailing Address - Fax:407-649-8363
Practice Address - Street 1:100 WEST GORE STREET STE 203
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1041
Practice Address - Country:US
Practice Address - Phone:407-649-8707
Practice Address - Fax:407-649-8363
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REHABILITATION MEDICAL GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5000-0064/320-000615261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID #