MEDICARE: SPINAL THERAPY MEDICAL GROUP FL

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	208D00000X	General Practice Physician	ME51866	FL
2	225100000X	Physical Therapist	PTA17624	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME51866	OTHER	FL	LICENSE
2	PTA17624	OTHER	FL	LICENSE
3	PT21956	OTHER	FL	LICENSE

General Provider Information

NPI Number	:	1750580460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINAL THERAPY MEDICAL GROUP FL

Provider Business Mailing Address
First Line	:	433 PLAZA REAL
Second Line	:	SUITE 255
City	:	BOCA RATON
State	:	FL
Zip	:	33432-3932
Country	:	US
Telephone Number	:	561-237-1717
Fax Number	:	561-237-1725

Provider Business Practice Location Address
First Line	:	433 PLAZA REAL
Second Line	:	SUITE 255
City	:	BOCA RATON
State	:	FL
Zip	:	33432-3932
Country	:	US
Telephone Number	:	561-237-1717
Fax Number	:	561-237-1725

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LORI WEISER
Credential	:	PTA
Telephone Number	:	561-237-1717

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	07/23/2007

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