Provider Demographics
NPI:1972541456
Name:BALGO, BRIAN J (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:J
Last Name:BALGO
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 1:711 WICKHAM LAKES DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2227
Mailing Address - Country:US
Mailing Address - Phone:321-795-6465
Mailing Address - Fax:321-633-0324
Practice Address - Street 1:2030 S PATRICK DR
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4400
Practice Address - Country:US
Practice Address - Phone:321-727-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT13777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY6368ZMedicare PIN