MEDICARE: ERIC LYLE GOSSELIN P.T., ATC, CSCS

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	2251X0800X	Orthopedic Physical Therapist	PT3292	ME
2	225100000X	Physical Therapist	PT 22300	FL
3	225100000X	Physical Therapist	17755	MA
4	2255A2300X	Athletic Trainer	AL 1851	FL

General Provider Information

NPI Number	:	1235342643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC LYLE GOSSELIN P.T., ATC, CSCS

Provider Business Mailing Address
First Line	:	275 BATH RD
Second Line	:	SUITE 2
City	:	BRUNSWICK
State	:	ME
Zip	:	04011-2671
Country	:	US
Telephone Number	:	407-791-3723
Fax Number	:

Provider Business Practice Location Address
First Line	:	82 VESPER ST
Second Line	:	APT 1
City	:	PORTLAND
State	:	ME
Zip	:	04101-4493
Country	:	US
Telephone Number	:	407-791-3723
Fax Number	:

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	02/24/2010

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