MEDICARE: GARY OSIRUS PTA

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	225200000X	Physical Therapy Assistant	40QB00283900	NJ

General Provider Information

NPI Number	:	1124372149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY OSIRUS PTA

Provider Business Mailing Address
First Line	:	3146 N JOG RD
Second Line	:	12211
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-7416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3146 N JOG RD
Second Line	:	12211
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-7416
Country	:	US
Telephone Number	:	772-480-8871
Fax Number	:

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

Provider Enumeration Date	:	10/29/2012
Last Update Date	:	10/29/2012

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