MEDICARE: PHYSICAL MEDICINE AND REHABILITATION, PA

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician	ME95874	FL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D02637	OTHER	FL	MEDICARE RAILROAD
4	P00667019	OTHER	FL	MEDICARE RAILROAD

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	93047	OTHER	FL	BCBSFL

NPI Number	:	1437343795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL MEDICINE AND REHABILITATION, PA

Provider Business Mailing Address
First Line	:	PO BOX 741240
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32774-1240
Country	:	US
Telephone Number	:	386-774-5211
Fax Number	:	386-774-5251

Provider Business Practice Location Address
First Line	:	1133 SAXON BLVD
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8470
Country	:	US
Telephone Number	:	386-775-7080
Fax Number	:	386-775-8070

Authorized Official
Title or Position	:	AGENT/REPRESENTATIVE
Name	:	MR. ROBERT COOLIDGE
Credential	:
Telephone Number	:	386-774-5211

Provider Enumeration Date	:	08/30/2007
Last Update Date	:	03/26/2009

3 SAINT STEPHENS PL , SUITE 2
WARWICK, NY
10990-3208

Practice Phone: 845-987-9700
Practice Fax: