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NPI Code Detail

MEDICARE: SHANNON M BOLGER PT, DPT

MEDICARE: SHANNON M BOLGER PT, DPT
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
12251P0200XPediatric Physical Therapist034096NY

General Provider Information

NPI Number : 1124306394
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANNON M BOLGER PT, DPT
Provider Business Mailing Address
First Line : 3255 BRIGHTON HENRIETTA TOWN LINE RD
Second Line : SUITE 102
City : ROCHESTER
State : NY
Zip : 14623-2806
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3255 BRIGHTON HENRIETTA TOWN LINE RD
Second Line : SUITE 102
City : ROCHESTER
State : NY
Zip : 14623-2806
Country : US
Telephone Number : 585-427-2977
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/21/2011
Last Update Date : 07/21/2011

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