Healthcare Provider Details

I. General information

NPI: 1689774838
Provider Name (Legal Business Name): REHABILITATION MEDICAL GRP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST GORE STREET STE 203
ORLANDO FL
32806-1041
US

IV. Provider business mailing address

100 WEST GORE STREET STE 203
ORLANDO FL
32806-1041
US

V. Phone/Fax

Practice location:
  • Phone: 407-649-8707
  • Fax: 407-649-8363
Mailing address:
  • Phone: 407-649-8707
  • Fax: 407-649-8363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number5000-0064/320-000615
License Number StateFL

VIII. Authorized Official

Name: MS. DIANE GREEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 407-649-8707