MEDICARE: ROLAND ORVIL WEBSTER IV DPT

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	PT012442	GA

General Provider Information

NPI Number	:	1881147411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROLAND ORVIL WEBSTER IV DPT

Provider Business Mailing Address
First Line	:	3455 HIGHWAY 81
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-9138
Country	:	US
Telephone Number	:	770-554-0665
Fax Number	:	770-554-0685

Provider Business Practice Location Address
First Line	:	3122 HIGHWAY 278 NW
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-2304
Country	:	US
Telephone Number	:	470-444-1609
Fax Number	:	470-444-1613

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

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	08/01/2016

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