MEDICARE: THOMAS BRADLEY MYRICK ATHLETIC TRAINER

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	527	AL

General Provider Information

NPI Number	:	1154505451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS BRADLEY MYRICK ATHLETIC TRAINER

Provider Business Mailing Address
First Line	:	970 ROBIN DR
Second Line	:
City	:	MOUNT OLIVE
State	:	AL
Zip	:	35117-3832
Country	:	US
Telephone Number	:	205-608-3083
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 MAIN ST
Second Line	:
City	:	GARDENDALE
State	:	AL
Zip	:	35071-2634
Country	:	US
Telephone Number	:	205-379-3600
Fax Number	:

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

Provider Enumeration Date	:	12/21/2007
Last Update Date	:	01/03/2008

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