Provider Demographics
NPI:1255415550
Name:PROFESSIONAL PHYSICAL THERAPY AND ASSOCIATES LTD CO
Entity type:Organization
Organization Name:PROFESSIONAL PHYSICAL THERAPY AND ASSOCIATES LTD CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MS
Authorized Official - Phone:386-423-0100
Mailing Address - Street 1:1316 S. RIDGEWOOD AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132
Mailing Address - Country:US
Mailing Address - Phone:386-423-0100
Mailing Address - Fax:386-428-8631
Practice Address - Street 1:1316 S. RIDGEWOOD AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132
Practice Address - Country:US
Practice Address - Phone:386-423-0100
Practice Address - Fax:386-428-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887120500Medicaid
FLY921BOtherBCBS
FLK2426Medicare ID - Type Unspecified