=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275112187
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW CHARLES SZERBIAK PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2021
-----------------------------------------------------
Last Update Date | 04/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 CELEBRATION PL
-----------------------------------------------------
City | CELEBRATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34747-4970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-303-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6008 HARWELL ESTATES DR
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33527-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 181-341-6492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA27311
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------