MEDICARE: MR. JASON BERTY PT, CSCS

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

General Provider Information

NPI Number	:	1063510303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON BERTY PT, CSCS

Provider Business Mailing Address
First Line	:	7424 SHADELAND STATION WAY
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-3925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7478 SHADELAND STATION WAY
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-3925
Country	:	US
Telephone Number	:	317-288-7606
Fax Number	:	317-288-7607

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	12/11/2018

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