MEDICARE: PROFESSIONAL SPORTS CARE MANAGEMENT INC

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	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1619938727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SPORTS CARE MANAGEMENT INC

Provider Business Mailing Address
First Line	:	1 BRANCA RD
Second Line	:
City	:	EAST RUTHERFORD
State	:	NJ
Zip	:	07073-2121
Country	:	US
Telephone Number	:	201-933-1112
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 BRANCA RD
Second Line	:
City	:	EAST RUTHERFORD
State	:	NJ
Zip	:	07073-2121
Country	:	US
Telephone Number	:	201-933-1112
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MICHAEL TARVIN
Credential	:
Telephone Number	:	717-975-4503

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	09/18/2007

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