MEDICARE: MR. JOSE MARTIN JORGE RRT

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	2279G1100X	General Care Registered Respiratory Therapist	0117003597	VA

General Provider Information

NPI Number	:	1063642692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSE MARTIN JORGE RRT

Provider Business Mailing Address
First Line	:	137 POINTER LN
Second Line	:
City	:	GORDONSVILLE
State	:	VA
Zip	:	22942-6864
Country	:	US
Telephone Number	:	434-984-2547
Fax Number	:

Provider Business Practice Location Address
First Line	:	137 POINTER LN
Second Line	:
City	:	GORDONSVILLE
State	:	VA
Zip	:	22942-6864
Country	:	US
Telephone Number	:	434-984-2547
Fax Number	:

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

Provider Enumeration Date	:	07/16/2009
Last Update Date	:	07/16/2009

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