MEDICARE: MR. GUEORGUI IVANOV PETROV MSPT

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	22949	FL

General Provider Information

NPI Number	:	1427125046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GUEORGUI IVANOV PETROV MSPT

Provider Business Mailing Address
First Line	:	4205 NW 73RD WAY
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-2156
Country	:	US
Telephone Number	:	954-478-9993
Fax Number	:

Provider Business Practice Location Address
First Line	:	2259 W HILLSBORO BLVD
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33442-1106
Country	:	US
Telephone Number	:	954-725-4160
Fax Number	:	954-725-4838

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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