MEDICARE: MICHEAL RAY GADDIE M.S., A.T.,C

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	AT218	KY

General Provider Information

NPI Number	:	1275664153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHEAL RAY GADDIE M.S., A.T.,C

Provider Business Mailing Address
First Line	:	592 FARMER LN
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42104-8546
Country	:	US
Telephone Number	:	270-745-5317
Fax Number	:	270-745-2412

Provider Business Practice Location Address
First Line	:	1906 COLLEGE HEIGHTS BLVD
Second Line	:
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-1000
Country	:	US
Telephone Number	:	270-745-5317
Fax Number	:

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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