MEDICARE: MS. MITZI KIM DUSIN 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	AT00213	RI

General Provider Information

NPI Number	:	1477685865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MITZI KIM DUSIN MS, ATC

Provider Business Mailing Address
First Line	:	1800 NEW LONDON TPKE
Second Line	:	APT. E-10
City	:	WEST WARWICK
State	:	RI
Zip	:	02893-5448
Country	:	US
Telephone Number	:	401-823-1275
Fax Number	:	401-874-4804

Provider Business Practice Location Address
First Line	:	1800 NEW LONDON TPKE
Second Line	:	APT. E-10
City	:	WEST WARWICK
State	:	RI
Zip	:	02893-5448
Country	:	US
Telephone Number	:	401-823-1275
Fax Number	:	401-874-4804

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

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	07/08/2007

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