MEDICARE: PATRICIA J KIDWELL OTR/L

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	225X00000X	Occupational Therapist	001950	GA

General Provider Information

NPI Number	:	1700865318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA J KIDWELL OTR/L

Provider Business Mailing Address
First Line	:	148 RICE ML
Second Line	:
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-5416
Country	:	US
Telephone Number	:	912-638-7174
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 PARKWOOD DR
Second Line	:	O.P. REHABILITATION
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-4722
Country	:	US
Telephone Number	:	912-466-5362
Fax Number	:

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

Provider Enumeration Date	:	01/12/2006
Last Update Date	:	02/27/2008

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