MEDICARE: MR. LEIGH JORDAN WEISS ATC, 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
1	2255A2300X	Athletic Trainer
2	2251S0007X	Sports Physical Therapist	40QA01381100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	984835	OTHER	NJ	NATA

General Provider Information

NPI Number	:	1144282252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEIGH JORDAN WEISS ATC, PT/DPT

Provider Business Mailing Address
First Line	:	224 BLOOMFIELD ST
Second Line	:	APT. 3
City	:	HOBOKEN
State	:	NJ
Zip	:	07030-4759
Country	:	US
Telephone Number	:	848-228-0246
Fax Number	:

Provider Business Practice Location Address
First Line	:	1925 GIANTS DR
Second Line	:	TIMEX PERFORMANCE CENTER
City	:	EAST RUTHERFORD
State	:	NJ
Zip	:	07073-2140
Country	:	US
Telephone Number	:	201-935-8111
Fax Number	:

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

Provider Enumeration Date	:	04/04/2006
Last Update Date	:	01/20/2011

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