Provider Demographics
NPI:1740239250
Name:MADONIA, KEITH RYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:RYAN
Last Name:MADONIA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 SW PROVIDENCE PL
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4385
Mailing Address - Country:US
Mailing Address - Phone:305-310-3702
Mailing Address - Fax:888-293-8662
Practice Address - Street 1:2042 SW PROVIDENCE PL
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4385
Practice Address - Country:US
Practice Address - Phone:305-310-3702
Practice Address - Fax:888-293-8662
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19334225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY056RYOtherMEDICARE PTAN
FLY056RZMedicare ID - Type Unspecified