MEDICARE: FAIRWAY PHYSICAL THERAPY LLC

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	225100000X	Physical Therapist	PT9631	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y915M	OTHER	FL	BCBS OF FL

General Provider Information

NPI Number	:	1376557090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAIRWAY PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	7100 FAIRWAY DR STE 42
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-3778
Country	:	US
Telephone Number	:	561-775-7775
Fax Number	:	561-293-2730

Provider Business Practice Location Address
First Line	:	7100 FAIRWAY DR STE 42
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33418-3778
Country	:	US
Telephone Number	:	561-775-7775
Fax Number	:	561-932-2730

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	LORI A SHUMAKER
Credential	:
Telephone Number	:	561-685-2492

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	08/07/2023

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