Basic Information
| Provider Information | |||||||||
| NPI: | 1548266836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEVENSON PHYSICAL THERAPY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STEVENSON & ASSOCIATES PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15620 MCGREGOR BLVD | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339082528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394546262 | ||||||||
| FaxNumber: | 2394540350 | ||||||||
| Practice Location | |||||||||
| Address1: | 15620 MCGREGOR BLVD | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339082528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394546262 | ||||||||
| FaxNumber: | 2394540350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 01/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | STEVENSON | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2394546262 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | PT0002829 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 3310940-001 | 01 | CIGNA HMO | OTHER | 0816278 | 01 | FL | AETNA HMO | OTHER | R4X | 01 | FL | BCBS OF FL | OTHER |