MEDICARE: MR. JUSTIN DANIEL MAHER ATC, PT, 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	2255A2300X	Athletic Trainer	25MT00168300	NJ

General Provider Information

NPI Number	:	1538407671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN DANIEL MAHER ATC, PT, DPT

Provider Business Mailing Address
First Line	:	211 PALSA AVE
Second Line	:
City	:	ELMWOOD PARK
State	:	NJ
Zip	:	07407-1216
Country	:	US
Telephone Number	:	201-873-0302
Fax Number	:	201-935-0889

Provider Business Practice Location Address
First Line	:	1925 GIANTS DR
Second Line	:
City	:	EAST RUTHERFORD
State	:	NJ
Zip	:	07073-2140
Country	:	US
Telephone Number	:	201-935-8111
Fax Number	:

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

Provider Enumeration Date	:	01/24/2013
Last Update Date	:	04/05/2018

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