Basic Information
| Provider Information | |||||||||
| NPI: | 1750835211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GAINESVILLE GERIATRIC REHABILITATION MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 NW 43RD ST | ||||||||
| Address2: | SUITE 102/387 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326064484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523281529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5002 NW 15TH PL | ||||||||
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| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523281529 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2016 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRANDT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3525146476 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | L16000146361 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.