MEDICARE: CONNOR BARNES ATC

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	2255A2300X	Athletic Trainer	AT. 004477	OH

General Provider Information

NPI Number	:	1114335692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNOR BARNES ATC

Provider Business Mailing Address
First Line	:	3834 HYDE PARK AVE APT 4
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45209-2045
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3800 VICTORY PKWY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45207-1035
Country	:	US
Telephone Number	:	314-402-0801
Fax Number	:

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

Provider Enumeration Date	:	07/28/2014
Last Update Date	:	07/28/2014

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