Basic Information
| Provider Information | |||||||||
| NPI: | 1578899688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POGUE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | KELLY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 S PATRICK DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217738155 | ||||||||
| FaxNumber: | 3217738154 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 S PATRICK DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217738155 | ||||||||
| FaxNumber: | 3217738154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2009 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-25067 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | K-3234 | 01 | FL | BEACHSIDE P.T. GROUP NUMBER | OTHER | PT-25067 | 01 | FL | STATE OF FL. PT LICENSE | OTHER |