MEDICARE: MS. MICHELLE THERESE MACKIN RPT

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	PT2382	OK

General Provider Information

NPI Number	:	1245451640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MICHELLE THERESE MACKIN RPT

Provider Business Mailing Address
First Line	:	1514 E 67TH CT
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3815
Country	:	US
Telephone Number	:	918-521-4273
Fax Number	:

Provider Business Practice Location Address
First Line	:	1514 E 67TH CT
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136-3815
Country	:	US
Telephone Number	:	918-521-4273
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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