MEDICARE: MR. MARK ALLEN LIVINGSTON P.T.

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	PT1692	MS

General Provider Information

NPI Number	:	1023119161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ALLEN LIVINGSTON P.T.

Provider Business Mailing Address
First Line	:	2416 HIGHWAY 45 N
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-1320
Country	:	US
Telephone Number	:	662-327-6705
Fax Number	:	662-327-6760

Provider Business Practice Location Address
First Line	:	1220 N SHORE PKWY
Second Line	:	SUITE B
City	:	BRANDON
State	:	MS
Zip	:	39047-6383
Country	:	US
Telephone Number	:	601-829-0505
Fax Number	:	601-829-0506

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	11/01/2016

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