Provider Demographics
NPI:1982984704
Name:PHYSICAL MEDICINE AND REHABILITATION CONSULTANT, LLC
Entity type:Organization
Organization Name:PHYSICAL MEDICINE AND REHABILITATION CONSULTANT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-260-8760
Mailing Address - Street 1:6175 SW 192ND AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33332
Mailing Address - Country:US
Mailing Address - Phone:919-260-8760
Mailing Address - Fax:
Practice Address - Street 1:6175 SW 192ND AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33332
Practice Address - Country:US
Practice Address - Phone:919-260-8760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 99900208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty