MEDICARE: BEACHSIDE PHYSICAL THERAPY, INC.

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CK5288	OTHER	FL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1457390874	OTHER	FL	NPI
3	Y901M	OTHER	FL	BCBS GROUP ID

General Provider Information

NPI Number	:	1457390874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHSIDE PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	660 E EAU GALLIE BLVD STE 106
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4252
Country	:	US
Telephone Number	:	321-773-5290
Fax Number	:	321-773-5268

Provider Business Practice Location Address
First Line	:	660 E EAU GALLIE BLVD STE 106
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4252
Country	:	US
Telephone Number	:	321-773-5290
Fax Number	:	321-773-5268

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	GABRIELA LITT
Credential	:
Telephone Number	:	951-696-9353

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	04/20/2021

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