Healthcare Provider Details

I. General information

NPI: 1467769455
Provider Name (Legal Business Name): KELLY M BAYZICK MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2010
Last Update Date: 09/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 BEEBE RUN RD
BRIDGETON NJ
08302-5679
US

IV. Provider business mailing address

310 BEEBE RUN RD
BRIDGETON NJ
08302-5679
US

V. Phone/Fax

Practice location:
  • Phone: 856-453-1584
  • Fax: 856-453-1486
Mailing address:
  • Phone: 856-453-1584
  • Fax: 856-453-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00417600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: