MEDICARE: STACY HOSP P.T.

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	2251X0800X	Orthopedic Physical Therapist	PT008126	GA

General Provider Information

NPI Number	:	1588995054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY HOSP P.T.

Provider Business Mailing Address
First Line	:	3777 PEACHTREE RD NE APT 1335
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30319-5201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3280 PEACHTREE RD NE
Second Line	:	225
City	:	ATLANTA
State	:	GA
Zip	:	30305-2430
Country	:	US
Telephone Number	:	404-254-4193
Fax Number	:

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

Provider Enumeration Date	:	01/24/2010
Last Update Date	:	01/24/2010

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