Basic Information
| Provider Information | |||||||||
| NPI: | 1871580969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL REHABILITATION ASSOCIATES, INC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1964 HOWELL BRANCH RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327921042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076812241 | ||||||||
| FaxNumber: | 4072796779 | ||||||||
| Practice Location | |||||||||
| Address1: | 6086 AUBURN CT | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410058022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048095312 | ||||||||
| FaxNumber: | 4102507756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHELTON | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | RANDOLPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3048095312 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 0113641000 | 05 | WV | MEDICAID | 7100210600 | 05 | KY | MEDICAID |