MEDICARE: SAMANTHA MCLEAN BRODIE DPT

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	225100000X	Physical Therapist	2305211851	VA

General Provider Information

NPI Number	:	1225503949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA MCLEAN BRODIE DPT

Provider Business Mailing Address
First Line	:	313 ESPLANADE PL
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-2005
Country	:	US
Telephone Number	:	503-791-3037
Fax Number	:

Provider Business Practice Location Address
First Line	:	5580 DANIEL SMITH RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-1104
Country	:	US
Telephone Number	:	757-499-7029
Fax Number	:

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

Provider Enumeration Date	:	10/09/2018
Last Update Date	:	10/09/2018

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