MEDICARE: CHAD IAN PERKINS M.S., ATC

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	AT0353	MS

General Provider Information

NPI Number	:	1427083716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD IAN PERKINS M.S., ATC

Provider Business Mailing Address
First Line	:	1005 CHICKASAW RD
Second Line	:
City	:	OXFORD
State	:	MS
Zip	:	38655-2707
Country	:	US
Telephone Number	:	662-236-5802
Fax Number	:

Provider Business Practice Location Address
First Line	:	DEPARTMENT OF INTERCOLLEGATE ATHLETICS
Second Line	:	RM.118 FIELDHOUSE
City	:	UNIVERSITY
State	:	MS
Zip	:	38677
Country	:	US
Telephone Number	:	662-915-7536
Fax Number	:	662-915-5275

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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