MEDICARE: KRISTOFER MICHAEL WILSON DPT

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	PT014219	OH

General Provider Information

NPI Number	:	1518303361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTOFER MICHAEL WILSON DPT

Provider Business Mailing Address
First Line	:	325 N MAIN ST
Second Line	:	SUITE 100
City	:	SPRINGBORO
State	:	OH
Zip	:	45066-8005
Country	:	US
Telephone Number	:	937-806-0318
Fax Number	:	937-806-0319

Provider Business Practice Location Address
First Line	:	325 N MAIN ST
Second Line	:	SUITE 100
City	:	SPRINGBORO
State	:	OH
Zip	:	45066-8005
Country	:	US
Telephone Number	:	937-806-0318
Fax Number	:	937-806-0319

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

Provider Enumeration Date	:	05/21/2013
Last Update Date	:	05/21/2013

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