MEDICARE: MS. MARIEKE VAN DER HORST P.T.

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	PT18940	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00165078	OTHER	FL	RAILROAD MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	Y9430	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1386620235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIEKE VAN DER HORST P.T.

Provider Business Mailing Address
First Line	:	504 BRIAR OAK WAY
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32724-8043
Country	:	US
Telephone Number	:	386-848-3091
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 N BEACH ST
Second Line	:	SUITE B
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5663
Country	:	US
Telephone Number	:	386-673-0201
Fax Number	:	386-677-8143

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

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	07/09/2008

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Directions to “ MS. MARIEKE VAN DER HORST P.T.” Practice Location

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