MEDICARE: MR. ROBERT D GREENE PTA

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	225200000X	Physical Therapy Assistant	PTA14096	FL

General Provider Information

NPI Number	:	1184757908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT D GREENE PTA

Provider Business Mailing Address
First Line	:	3193 OAKPARK DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33803-7957
Country	:	US
Telephone Number	:	863-607-6065
Fax Number	:	863-607-6065

Provider Business Practice Location Address
First Line	:	8800 GRAND OAK CIR
Second Line	:	SUITE 450
City	:	TAMPA
State	:	FL
Zip	:	33637-2006
Country	:	US
Telephone Number	:	813-558-6505
Fax Number	:	813-975-1016

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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