MEDICARE: GINA MARIA DICROCCO ATC

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	AT84	ME

General Provider Information

NPI Number	:	1679573224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA MARIA DICROCCO ATC

Provider Business Mailing Address
First Line	:	39 HIGH STREET
Second Line	:
City	:	STRONG
State	:	ME
Zip	:	04983
Country	:	US
Telephone Number	:	207-491-1056
Fax Number	:	207-779-2585

Provider Business Practice Location Address
First Line	:	111 FRANKLIN HEALTH CMNS
Second Line	:
City	:	FARMINGTON
State	:	ME
Zip	:	04938-6144
Country	:	US
Telephone Number	:	207-779-2621
Fax Number	:	207-779-2585

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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