MEDICARE: MARTIN PAUL AUDYCKI 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	10363	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10363	OTHER	NY	PT LICENSE NUMBER
2	11225297	OTHER	NY	CAQH ID NUMBER

General Provider Information

NPI Number	:	1023103959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN PAUL AUDYCKI PT

Provider Business Mailing Address
First Line	:	1564 LONG POND RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-4119
Country	:	US
Telephone Number	:	585-227-2580
Fax Number	:	585-227-3077

Provider Business Practice Location Address
First Line	:	1564 LONG POND RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-4119
Country	:	US
Telephone Number	:	585-227-2580
Fax Number	:	585-227-3077

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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