Healthcare Provider Details

I. General information

NPI: 1104947423
Provider Name (Legal Business Name): EDWARD BARRY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10341 SE US HIGHWAY 441
BELLEVIEW FL
34420-2807
US

IV. Provider business mailing address

10341 SE US HIGHWAY 441
BELLEVIEW FL
34420-2807
US

V. Phone/Fax

Practice location:
  • Phone: 352-307-0066
  • Fax: 352-307-9556
Mailing address:
  • Phone: 352-307-0066
  • Fax: 352-307-9556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 12511
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: