MEDICARE: ANTHONY W GAMBILL A.T.C., CSCS

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	36000011A	IN

General Provider Information

NPI Number	:	1588658140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY W GAMBILL A.T.C., CSCS

Provider Business Mailing Address
First Line	:	7302 JASMINE PL
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-3196
Country	:	US
Telephone Number	:	260-483-3071
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 SPRING ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-3939
Country	:	US
Telephone Number	:	260-399-7700
Fax Number	:	260-399-8164

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

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	03/29/2010

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