MEDICARE: MS. MARCUS MARTIN PEDIGO MASTERS

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1780753780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARCUS MARTIN PEDIGO MASTERS

Provider Business Mailing Address
First Line	:	1111 CRESTVIEW DRIVE
Second Line	:
City	:	CAVE CITY
State	:	KY
Zip	:	42127
Country	:	US
Telephone Number	:	270-773-2693
Fax Number	:	270-773-2693

Provider Business Practice Location Address
First Line	:	1111 CRESTVIEW DRIVE
Second Line	:
City	:	CAVE CITY
State	:	KY
Zip	:	42127-0000
Country	:	US
Telephone Number	:	270-773-2693
Fax Number	:	270-773-2693

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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