MEDICARE: FIVE STAR PHYSICAL THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	PT30070	FL

General Provider Information

NPI Number	:	1225420623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIVE STAR PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	236 PONTE VEDRA PARK DR
Second Line	:	SUITE 300
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-6619
Country	:	US
Telephone Number	:	904-280-3440
Fax Number	:	904-280-3444

Provider Business Practice Location Address
First Line	:	236 PONTE VEDRA PARK DR
Second Line	:	SUITE 300
City	:	PONTE VEDRA
State	:	FL
Zip	:	32082-6619
Country	:	US
Telephone Number	:	904-280-3440
Fax Number	:	904-280-3444

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MELISSA ROBERSON
Credential	:
Telephone Number	:	904-280-3440

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	02/23/2015

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Practice Location Address:

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1831624527 — PT SOLUTIONS OF PENSACOLA, LLC
Practice Location Address:

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Practice Fax:

Directions to “FIVE STAR PHYSICAL THERAPY ” Practice Location

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