MEDICARE: EMILY SUE HAYWOOD 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	1879	MN

General Provider Information

NPI Number	:	1932264777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY SUE HAYWOOD ATC

Provider Business Mailing Address
First Line	:	300 W 96TH ST
Second Line	:	APT 1 F
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-4375
Country	:	US
Telephone Number	:	952-836-7808
Fax Number	:

Provider Business Practice Location Address
First Line	:	9701 NICOLLET AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55420-4448
Country	:	US
Telephone Number	:	952-681-5207
Fax Number	:

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

Provider Enumeration Date	:	12/22/2006
Last Update Date	:	07/08/2007

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