MEDICARE: MR. PERIASWAMY SUBASH CHANDAR P.T.

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	PT 0011706	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y020X	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1497889208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PERIASWAMY SUBASH CHANDAR P.T.

Provider Business Mailing Address
First Line	:	6710 WINKLER RD
Second Line	:	UNIT # 4
City	:	FORT MYERS
State	:	FL
Zip	:	33919-7274
Country	:	US
Telephone Number	:	239-437-6620
Fax Number	:	239-437-6619

Provider Business Practice Location Address
First Line	:	6710 WINKLER RD
Second Line	:	UNIT # 4
City	:	FORT MYERS
State	:	FL
Zip	:	33919-7274
Country	:	US
Telephone Number	:	239-437-6620
Fax Number	:	239-437-6619

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	07/08/2007

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