Provider Demographics
NPI:1245289032
Name:PANDOLPH, RUTH M (PT)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:M
Last Name:PANDOLPH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 COMMERCE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-1549
Mailing Address - Country:US
Mailing Address - Phone:407-873-5311
Mailing Address - Fax:
Practice Address - Street 1:305 COMMERCE CENTER DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-1549
Practice Address - Country:US
Practice Address - Phone:407-873-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780915181OtherFACILITY NPI (COMPREHENSIVE PAIN RELIEF)
FL888581800Medicaid