MEDICARE: PREMIER PHYSICAL THERAPY SPORT MEDICINE INC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CK5189	OTHER	FL	RAILROAD MEDICARE PTAN
3	650023083	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	Y904G	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1265542682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PHYSICAL THERAPY SPORT MEDICINE INC

Provider Business Mailing Address
First Line	:	PO BOX 8600
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34985
Country	:	US
Telephone Number	:	772-335-7966
Fax Number	:	772-335-7963

Provider Business Practice Location Address
First Line	:	800 VIRGINIA AVE STE 48
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5893
Country	:	US
Telephone Number	:	772-464-6424
Fax Number	:	772-464-4324

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JEFFREY ALAN TUCKER
Credential	:	MPT
Telephone Number	:	772-335-7966

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	02/19/2020

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