=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659490324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TOMISLAV PENDZIC COTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 SALISBURY ST
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-798-8653
-----------------------------------------------------
Fax | 508-792-5809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 BARROWS RD
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01609-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-798-7879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 2898
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------