MEDICARE: AUGUSTA HIXON POLHEMUS 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	13123	MA

General Provider Information

NPI Number	:	1851955512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUGUSTA HIXON POLHEMUS OTR/L

Provider Business Mailing Address
First Line	:	58 RUTLAND ST UNIT 2
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-1526
Country	:	US
Telephone Number	:	617-306-1123
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 FOREST RIDGE RD
Second Line	:
City	:	CONCORD
State	:	MA
Zip	:	01742-3844
Country	:	US
Telephone Number	:	978-287-7878
Fax Number	:

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

Provider Enumeration Date	:	04/29/2019
Last Update Date	:	04/29/2019

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