=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912318924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN PHILLIPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2014
-----------------------------------------------------
Last Update Date | 05/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17842 NW 2ND ST
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-2806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-367-4000
-----------------------------------------------------
Fax | 954-367-4010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16249 BISCAYNE BLVD
-----------------------------------------------------
City | AVENTURA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33160-4300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-405-0400
-----------------------------------------------------
Fax | 305-405-0415
-----------------------------------------------------
=====================================================
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 | PTA24746
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------