MEDICARE: JILLIAN SURRIDGE DPT

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134785280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN SURRIDGE DPT

Provider Business Mailing Address
First Line	:	4714 N HABANA AVE APT 3003
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-7141
Country	:	US
Telephone Number	:	845-661-9330
Fax Number	:

Provider Business Practice Location Address
First Line	:	4539 S DALE MABRY HWY STE 110
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-1404
Country	:	US
Telephone Number	:	813-250-1208
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	05/14/2019

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