Basic Information
| Provider Information | |||||||||
| NPI: | 1326286816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTACROSS | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANTACROSS | ||||||||
| OtherFirstName: | ADAM | ||||||||
| OtherMiddleName: | MICHAEL | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8455 S SUNCOAST BLVD | ||||||||
| Address2: | |||||||||
| City: | HOMOSASSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344465066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524655880 | ||||||||
| FaxNumber: | 3524655889 | ||||||||
| Practice Location | |||||||||
| Address1: | 20726 W PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | DUNNELLON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344316717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524655880 | ||||||||
| FaxNumber: | 3524655889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA21567 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 106898 | 01 | FL | MEDICARE ID | OTHER |