MEDICARE: INTEGRATIVE PHYSICAL MEDICINE OF LAKE MARY LLC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1043637861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE PHYSICAL MEDICINE OF LAKE MARY LLC

Provider Business Mailing Address
First Line	:	1343 S INTERNATIONAL PKWY
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1401
Country	:	US
Telephone Number	:	407-792-0705
Fax Number	:	407-792-0710

Provider Business Practice Location Address
First Line	:	1343 S INTERNATIONAL PKWY
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1401
Country	:	US
Telephone Number	:	407-792-0705
Fax Number	:	407-792-0710

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARC OTT
Credential	:
Telephone Number	:	407-792-0705

Provider Enumeration Date	:	03/19/2014
Last Update Date	:	06/01/2016

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