MEDICARE: PHYSIOLOGIX SPORTS PHYSICAL THERAPY 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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1457186801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSIOLOGIX SPORTS PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	185 SE 14TH TER APT 906
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33131-3415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6055 SANDY SPRINGS CIR
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-3863
Country	:	US
Telephone Number	:	305-902-6644
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT POLISZUK
Credential	:
Telephone Number	:	305-902-6644

Provider Enumeration Date	:	09/05/2024
Last Update Date	:	09/05/2024

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