MEDICARE: MR. OMAR TATUM

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	225200000X	Physical Therapy Assistant	1198-19	WI

General Provider Information

NPI Number	:	1114177623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OMAR TATUM

Provider Business Mailing Address
First Line	:	1435 W BROWN ST
Second Line	:	APT 3
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1227
Country	:	US
Telephone Number	:	414-418-8608
Fax Number	:

Provider Business Practice Location Address
First Line	:	1435 W BROWN ST
Second Line	:	APT 3
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1227
Country	:	US
Telephone Number	:	414-418-8608
Fax Number	:

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

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	09/22/2008

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