=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306350889
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK WORK PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 CHILLICOTHE AVE
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45133-1533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-393-1925
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 GUILFORD BLVD
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-2727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-410-3783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251G0304X
-----------------------------------------------------
Taxonomy Name | Geriatric Physical Therapist
-----------------------------------------------------
License Number | 03873
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------