Provider Demographics
NPI:1720096720
Name:PHYSIO MED INC
Entity Type:Organization
Organization Name:PHYSIO MED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-589-5595
Mailing Address - Street 1:2765 S BAY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6501
Mailing Address - Country:US
Mailing Address - Phone:352-589-5595
Mailing Address - Fax:352-589-5747
Practice Address - Street 1:2765 S BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6501
Practice Address - Country:US
Practice Address - Phone:352-589-5955
Practice Address - Fax:352-589-5747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
72890070OtherAETNA
FLQ3NOtherBCBS
72890070OtherAETNA