MEDICARE: RUSSELL CHALMERS COTA

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	224Z00000X	Occupational Therapy Assistant	46TA09094700	NJ

General Provider Information

NPI Number	:	1467852392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL CHALMERS COTA

Provider Business Mailing Address
First Line	:	30 CHESTNUT ST
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-5612
Country	:	US
Telephone Number	:	845-820-1953
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 CHESTNUT ST
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10940-5612
Country	:	US
Telephone Number	:	845-820-1953
Fax Number	:

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

Provider Enumeration Date	:	08/28/2014
Last Update Date	:	08/28/2014

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