MEDICARE: TAMARA OSTERHOUT MS, LAT

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	25MT00174500	NJ

General Provider Information

NPI Number	:	1740889567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA OSTERHOUT MS, LAT

Provider Business Mailing Address
First Line	:	131 W END AVE
Second Line	:
City	:	HADDONFIELD
State	:	NJ
Zip	:	08033-2617
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 JACKSONVILLE RD
Second Line	:
City	:	MOUNT HOLLY
State	:	NJ
Zip	:	08060-1239
Country	:	US
Telephone Number	:	860-402-9069
Fax Number	:

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

Provider Enumeration Date	:	10/22/2020
Last Update Date	:	10/22/2020

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