MEDICARE: DR. LARRY G WELLS DPM

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	213E00000X	Podiatrist	SC2671L	PA

General Provider Information

NPI Number	:	1912905324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY G WELLS DPM

Provider Business Mailing Address
First Line	:	361 WORTH ST
Second Line	:
City	:	CORRY
State	:	PA
Zip	:	16407-1410
Country	:	US
Telephone Number	:	814-663-3668
Fax Number	:	814-665-4434

Provider Business Practice Location Address
First Line	:	361 WORTH ST
Second Line	:
City	:	CORRY
State	:	PA
Zip	:	16407-1410
Country	:	US
Telephone Number	:	814-663-3668
Fax Number	:	814-665-4434

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

Provider Enumeration Date	:	07/09/2005
Last Update Date	:	07/08/2007

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