MEDICARE: MR. JUSTIN MARK KOTLARCZYK PT

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	PT21555	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y060C	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1649255852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN MARK KOTLARCZYK PT

Provider Business Mailing Address
First Line	:	100 3RD AVE W
Second Line	:	STE 110
City	:	BRADENTON
State	:	FL
Zip	:	34205-8641
Country	:	US
Telephone Number	:	941-708-9555
Fax Number	:	941-708-5200

Provider Business Practice Location Address
First Line	:	2722 MANATEE AVE W
Second Line	:	SUITE 2
City	:	BRADENTON
State	:	FL
Zip	:	34205-4945
Country	:	US
Telephone Number	:	941-744-9046
Fax Number	:	941-744-9046

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2005
Last Update Date	:	08/10/2018

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