MEDICARE: MRS. JAN M ANDERSON 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	2651	CT

General Provider Information

NPI Number	:	1316036338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JAN M ANDERSON RPT

Provider Business Mailing Address
First Line	:	1 OLD PARK LANE
Second Line	:
City	:	NEW MILFORD
State	:	CT
Zip	:	06776
Country	:	US
Telephone Number	:	860-355-2213
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 OLD PARK LANE RD
Second Line	:
City	:	NEW MILFORD
State	:	CT
Zip	:	06776-2507
Country	:	US
Telephone Number	:	860-355-2213
Fax Number	:

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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