Basic Information
| Provider Information | |||||||||
| NPI: | 1487872651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NASSAU PHYSICAL THERAPY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1609 | ||||||||
| Address2: | |||||||||
| City: | CALLAHAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320111609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048791223 | ||||||||
| FaxNumber: | 9048791223 | ||||||||
| Practice Location | |||||||||
| Address1: | 45390 GREEN AVE | ||||||||
| Address2: | |||||||||
| City: | CALLAHAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320113711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048791223 | ||||||||
| FaxNumber: | 9048791223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | MARINO | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9042774449 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT 5539 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | Y927Q | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER | Y907M | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |