MEDICARE: MR. TODD LANE EMERSON INDEPENDENT DUTY HS

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	1710I1002X	Independent Duty Corpsman
2	247200000X	Other Technician

General Provider Information

NPI Number	:	1043296320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TODD LANE EMERSON INDEPENDENT DUTY HS

Provider Business Mailing Address
First Line	:	1 MUNRO AVE
Second Line	:
City	:	CAPE MAY
State	:	NJ
Zip	:	08204-5000
Country	:	US
Telephone Number	:	609-898-6860
Fax Number	:	609-898-6962

Provider Business Practice Location Address
First Line	:	1 MUNRO AVE
Second Line	:
City	:	CAPE MAY
State	:	NJ
Zip	:	08204-5000
Country	:	US
Telephone Number	:	609-898-6860
Fax Number	:	609-898-6962

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

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	10/27/2009

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