MEDICARE: DR. TAMMY L. PORTOLESE D.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	111N00000X	Chiropractor	DC007023L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0967764000	OTHER	PA	KEYSTONE & PC
2	2582972	OTHER	PA	AETNA
3	1303194	OTHER	PA	BC / BS

General Provider Information

NPI Number	:	1306848395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAMMY L. PORTOLESE D.C.

Provider Business Mailing Address
First Line	:	118 DICKERSON RD
Second Line	:	SUITE C
City	:	NORTH WALES
State	:	PA
Zip	:	19454-2538
Country	:	US
Telephone Number	:	215-661-8533
Fax Number	:	215-661-8535

Provider Business Practice Location Address
First Line	:	118 DICKERSON RD
Second Line	:	SUITE C
City	:	NORTH WALES
State	:	PA
Zip	:	19454-2538
Country	:	US
Telephone Number	:	215-661-8533
Fax Number	:	215-661-8535

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/08/2007

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