MEDICARE: MR. BENJAMIN BRANDT TAYLOR RPT

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	225100000X	Physical Therapist	1102895	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	381860	OTHER		FIRSTGUARD
2	1102895	OTHER	KS	KS STATE LICENSE

General Provider Information

NPI Number	:	1770576852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN BRANDT TAYLOR RPT

Provider Business Mailing Address
First Line	:	PO BOX 623
Second Line	:
City	:	CHANUTE
State	:	KS
Zip	:	66720-0623
Country	:	US
Telephone Number	:	620-431-0887
Fax Number	:	620-431-0816

Provider Business Practice Location Address
First Line	:	305 N WASHINGTON AVE
Second Line	:
City	:	IOLA
State	:	KS
Zip	:	66749-2350
Country	:	US
Telephone Number	:	620-431-0887
Fax Number	:	620-431-0887

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

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	07/08/2007

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