Basic Information
| Provider Information | |||||||||
| NPI: | 1891739702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEMELT | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | LEO | ||||||||
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| Credential: | DPT MOTR L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 SALTWATER CIR | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320806305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044600079 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 ORTHOPAEDIC PL | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320864202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048250540 | ||||||||
| FaxNumber: | 9042091057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT21456 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225XH1200X | OT11336 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225X00000X | OT11336 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 002844900 | 05 | FL | MEDICAID | P00667168 | 01 | MEDICARE RAILROAD | OTHER | 1174540001 | 01 | FL | CIGNA GOVT SVCS DMERC | OTHER |