MEDICARE: SERENA I BASCIANO PT, MSPT

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	40QA01443500	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	049801DBD	OTHER	NJ	MEDICARE

General Provider Information

NPI Number	:	1154672632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERENA I BASCIANO PT, MSPT

Provider Business Mailing Address
First Line	:	PO BOX 1014
Second Line	:
City	:	CLARK
State	:	NJ
Zip	:	07066-1014
Country	:	US
Telephone Number	:	732-855-9751
Fax Number	:	732-855-9755

Provider Business Practice Location Address
First Line	:	266-272 CHESTNUT ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-6521
Country	:	US
Telephone Number	:	973-732-3850
Fax Number	:	973-732-3853

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

Provider Enumeration Date	:	09/25/2012
Last Update Date	:	01/14/2015

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