MEDICARE: MR. KEVIN WEISBACH MS, 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	25MT00141900	NJ

General Provider Information

NPI Number	:	1427233527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN WEISBACH MS, ATC

Provider Business Mailing Address
First Line	:	2641 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5943
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 KENNEDY BLVD
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-5943
Country	:	US
Telephone Number	:	201-761-7326
Fax Number	:

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

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	01/08/2008

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