NPIMap

Organization Active NPI

Premier Physical Therapy Sport Medicine Inc

  • Physical Therapist
  • Port St Lucie, FL
National Provider Identifier
1417067844
Registry record updated Feb 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
PREMIER PHYSICAL THERAPY SPORT MEDICINE INC
Practice address
1400 SE Goldtree Dr
Ste 205
Port St Lucie, FL 34952-7582
Phone
(772) 335-7966
Fax
(772) 335-7963
NPI assigned
Aug 30, 2006
Last updated
Feb 19, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 19, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jeffrey Alan Tucker, MPTNPI 1982725230
Title
Executive Director
Phone
(772) 335-7966

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X NU Primary

Addresses

Primary practice location

1400 SE Goldtree Dr
Ste 205
Port St Lucie, FL 34952-7582

Mailing address

PO Box 8600
Port St Lucie, FL 34985
Phone (772) 335-7966

Other identifiers 3

IdentifierTypeStateIssuer
Y903WOtherFLBCBS PROVIDER NUMBER
CK5189OtherFLRAILROAD MEDICARE PTAN
650023083OtherFLRAILROAD MEDICARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040318000876 FL Part B Supplier - Clinic/Group Practice 3173413549 Receives reassigned benefits from 59 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Palm City, FL; West Palm Beach, FL; Vero Beach, FL; Stuart, FL; Port St Lucie, FL; Melbourne, FL; Jensen Beach, FL; Fort Pierce, FL…

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

10560 SW Village Pkwy
Port St Lucie, FL 34987
Phone (772) 446-0203

5054 SE Federal Hwy
Stuart, FL 34997
Phone (772) 419-7325

Networks

  • Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Máximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…
  • Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)

Practitioners & affiliated clinicians

Practitioners 75

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 75

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156896000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582070400000",
    "number": "1417067844",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 8600",
            "city": "PORT ST LUCIE",
            "state": "FL",
            "postal_code": "34985",
            "telephone_number": "772-335-7966",
            "fax_number": "772-335-7963"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1400 SE GOLDTREE DR",
            "address_2": "STE 205",
            "city": "PORT ST LUCIE",
            "state": "FL",
            "postal_code": "349527582",
            "telephone_number": "772-335-7966",
            "fax_number": "772-335-7963"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PREMIER PHYSICAL THERAPY SPORT MEDICINE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-30",
        "last_updated": "2020-02-19",
        "certification_date": "2020-02-19",
        "status": "A",
        "authorized_official_last_name": "TUCKER",
        "authorized_official_first_name": "JEFFREY",
        "authorized_official_middle_name": "ALAN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "772-335-7966",
        "authorized_official_credential": "MPT"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PROVIDER NUMBER",
            "identifier": "Y903W",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE PTAN",
            "identifier": "CK5189",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "650023083",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Port St Lucie, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.