Provider Demographics
NPI:1841583812
Name:ANDERSON, BRIAN MARK (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MARK
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24945 US HIGHWAY 19 N
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-3927
Mailing Address - Country:US
Mailing Address - Phone:727-726-1460
Mailing Address - Fax:727-724-9705
Practice Address - Street 1:1001 37TH ST N STE D
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-6010
Practice Address - Country:US
Practice Address - Phone:727-914-9130
Practice Address - Fax:279-149-1317
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18172225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFS926ZMedicare PIN