Ivan Broaderick Gresham
Individual provider Active NPI Physical Therapy Assistant · Callahan, FL
NPI 1457789653 · NPPES record last updated Oct 24, 2013
Key facts
- NPI
- 1457789653
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physical Therapy Assistant 225200000X
- License
- PTA24242 (FL)
- Practice address
- 45390 Green Ave
Callahan, FL 32011-3711 - Phone
- (904) 879-1223
- NPI assigned
- Oct 24, 2013
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PTA24242 | FL | MD | Physical Therapy Assistant |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | PTA24242 | FL | Yes |
Addresses
Primary practice location
45390 Green Ave
Callahan, FL 32011-3711
Mailing address
45390 Green Ave
Callahan, FL 32011-3711
Phone (904) 879-1223
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| PTA24242 | Other | FL | STATE LICENSE # |
Other providers in Callahan, FL
- Robert Ethan Gentry
- Janet Byrd Gilbert
- Great Strides Rehabilitation Inc.
- Great Strides Rehabilitation Inc.
- Steven K Greenhut
- Erin Leigh Grimaldi
- Warren S Groff
- Swathi Gunturu
- H2 Rehabilitation Services of Florida LLC
- Cassandra Hargis
All providers in Callahan, FL · Physical Therapy Assistant in Florida
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 24, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.