MEDICARE: DR. THOMAS BRADLEY VICKERS DPT, ATC

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	2305214533	VA
2	225100000X	Physical Therapist	008502	KY
3	225100000X	Physical Therapist	10947	SC
4	2255A2300X	Athletic Trainer	AL4563	FL
5	225100000X	Physical Therapist	PT37213	FL

General Provider Information

NPI Number	:	1568924348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS BRADLEY VICKERS DPT, ATC

Provider Business Mailing Address
First Line	:	11911 CORNELIUS ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-4004
Country	:	US
Telephone Number	:	904-234-4446
Fax Number	:

Provider Business Practice Location Address
First Line	:	1852 SW BARNETT WAY STE 101
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6953
Country	:	US
Telephone Number	:	386-752-7332
Fax Number	:

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

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	04/06/2022

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