MEDICARE: INTEGRATIVE PHYSICAL MEDICINE, LLC

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		FL

General Provider Information

NPI Number	:	1417208844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE PHYSICAL MEDICINE, LLC

Provider Business Mailing Address
First Line	:	425 ALEXANDRIA BLVD STE 1010
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765-5548
Country	:	US
Telephone Number	:	321-244-4644
Fax Number	:	407-977-3433

Provider Business Practice Location Address
First Line	:	425 ALEXANDRIA BLVD STE 1010
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765-5548
Country	:	US
Telephone Number	:	321-244-4644
Fax Number	:	407-977-3433

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARC OTT
Credential	:	DO
Telephone Number	:	407-977-3434

Provider Enumeration Date	:	09/25/2012
Last Update Date	:	09/25/2012

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