MEDICARE: MS. MEGHAN ELIZABETH PEDUTO MS, 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	001396	NY

General Provider Information

NPI Number	:	1790890671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MEGHAN ELIZABETH PEDUTO MS, ATC

Provider Business Mailing Address
First Line	:	40 BROADWAY UNIT 28
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12202-1020
Country	:	US
Telephone Number	:	518-727-0449
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 N BROADWAY
Second Line	:
City	:	SARATOGA SPRINGS
State	:	NY
Zip	:	12866-1632
Country	:	US
Telephone Number	:	518-580-5390
Fax Number	:

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	07/08/2007

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