MEDICARE: MR. ANDREW JOSEPH GODEK ATC, PT

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	2255A2300X	Athletic Trainer	AL2080	FL
2	225100000X	Physical Therapist	PT26195	FL

General Provider Information

NPI Number	:	1689635732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREW JOSEPH GODEK ATC, PT

Provider Business Mailing Address
First Line	:	1348 S. 18TH STREET
Second Line	:	BAPTIST REHAB
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034
Country	:	US
Telephone Number	:	904-321-3850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1348 SOUTH 18TH STREET
Second Line	:	BAPTIST REHAB
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034
Country	:	US
Telephone Number	:	904-321-3850
Fax Number	:

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

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	02/16/2018

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