MEDICARE: MR. SCOTT MICHAEL PETERSON ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	000727-1	NY

General Provider Information

NPI Number	:	1033126974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT MICHAEL PETERSON ATC

Provider Business Mailing Address
First Line	:	LEMOYNE COLLEGE SPORTS MEDICINE
Second Line	:	1419 SALT SPRINGS ROAD
City	:	SYRACUSE
State	:	NY
Zip	:	13214-1399
Country	:	US
Telephone Number	:	315-445-4417
Fax Number	:	315-445-6048

Provider Business Practice Location Address
First Line	:	LEMOYNE COLLEGE SPORTS MEDICINE
Second Line	:	1419 SALT SPRINGS ROAD
City	:	SYRACUSE
State	:	NY
Zip	:	13214-1399
Country	:	US
Telephone Number	:	315-445-4417
Fax Number	:	315-445-6048

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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