MEDICARE: PAMELA ELENE GJERDE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT008073	OTHER	GA	LICENSE #

General Provider Information

NPI Number	:	1073623666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA ELENE GJERDE PT

Provider Business Mailing Address
First Line	:	6308 DRUID HILLS RESERVE DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2056
Country	:	US
Telephone Number	:	678-371-3688
Fax Number	:

Provider Business Practice Location Address
First Line	:	57 EXECUTIVE PARK SOUTH NE
Second Line	:	STE 190
City	:	ATLANTA
State	:	GA
Zip	:	30329-2288
Country	:	US
Telephone Number	:	404-778-6390
Fax Number	:	404-778-6340

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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