MEDICARE: PHYSIO MED INC

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	261QR0400X	Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	72890070	OTHER		AETNA
2	Q3N	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1720096720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSIO MED INC

Provider Business Mailing Address
First Line	:	2765 S BAY ST
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32726-6501
Country	:	US
Telephone Number	:	352-589-5595
Fax Number	:	352-589-5747

Provider Business Practice Location Address
First Line	:	2765 S BAY ST
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32726-6501
Country	:	US
Telephone Number	:	352-589-5955
Fax Number	:	352-589-5747

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SCOTTIE BULL
Credential	:
Telephone Number	:	352-589-5595

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	02/02/2022

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Directions to “PHYSIO MED INC ” Practice Location

Language	Start Address	Practice Location

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