MEDICARE: KENNETH SHILDT PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT011171L	PA

General Provider Information

NPI Number	:	1023024502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH SHILDT PT

Provider Business Mailing Address
First Line	:	1116 MANSFIELD AVE
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-2416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	612 SALT ST
Second Line	:
City	:	SALTSBURG
State	:	PA
Zip	:	15681-1128
Country	:	US
Telephone Number	:	724-639-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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