=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407872898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCUS OSBORNE ATC; LAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 8TH AVE SW
-----------------------------------------------------
City | MAGEE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39111-3967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-849-4112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 371 SOUTHWIND DR
-----------------------------------------------------
City | RICHLAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39218-9229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | AT0292
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------