=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306508338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD TOMCZYK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2021
-----------------------------------------------------
Last Update Date | 10/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 146 CHAPEL HARBOR DR
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15238-3154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-533-8404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 FEDERAL ST STE 115B
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15212-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-533-8404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT002093A
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------