MEDICARE: MRS. ILENE S WATROUS PT

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	40QA00312200	NJ

General Provider Information

NPI Number	:	1881678761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ILENE S WATROUS PT

Provider Business Mailing Address
First Line	:	131 CRANBURY RD
Second Line	:
City	:	PRINCETON JUNCTION
State	:	NJ
Zip	:	08550-1205
Country	:	US
Telephone Number	:	609-799-5204
Fax Number	:	609-799-5205

Provider Business Practice Location Address
First Line	:	131 CRANBURY RD
Second Line	:
City	:	PRINCETON JUNCTION
State	:	NJ
Zip	:	08550-1205
Country	:	US
Telephone Number	:	609-799-5204
Fax Number	:	609-799-5205

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

Provider Enumeration Date	:	12/03/2005
Last Update Date	:	07/08/2007

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