MEDICARE: INJURY TREATMENT CENTER OF CORAL SPRINGS 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	208D00000X	General Practice Physician	HCC3662	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34548	OTHER	FL	BLUE SHIELD NUMBER

General Provider Information

NPI Number	:	1396866653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INJURY TREATMENT CENTER OF CORAL SPRINGS INC

Provider Business Mailing Address
First Line	:	2295 NW CORPORATE BLVD
Second Line	:	SUITE 140
City	:	BOCA RATON
State	:	FL
Zip	:	33431-7373
Country	:	US
Telephone Number	:	561-241-1971
Fax Number	:	561-241-3969

Provider Business Practice Location Address
First Line	:	871 W OAKLAND PARK BLVD
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-1731
Country	:	US
Telephone Number	:	954-567-5730
Fax Number	:	954-567-5733

Authorized Official
Title or Position	:	CREDENTIALING DEPT
Name	:	EVAN SADE
Credential	:
Telephone Number	:	954-817-9402

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	04/20/2008

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