MEDICARE: TRICIA GALLUP PT

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	6446	MN

General Provider Information

NPI Number	:	1275552937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRICIA GALLUP PT

Provider Business Mailing Address
First Line	:	PO BOX 2298
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56302-2298
Country	:	US
Telephone Number	:	320-203-9045
Fax Number	:	320-203-9539

Provider Business Practice Location Address
First Line	:	35 LAKE ST S
Second Line	:	STE 600
City	:	BIG LAKE
State	:	MN
Zip	:	55309
Country	:	US
Telephone Number	:	763-263-6565
Fax Number	:

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/08/2007

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