MEDICARE: ATHENS SPORTS MEDICINE CLINIC INC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1174528103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHENS SPORTS MEDICINE CLINIC INC

Provider Business Mailing Address
First Line	:	4714 GETTYSBURG RD
Second Line	:	LEGAL DEPARTMENT
City	:	MECHANICSBURG
State	:	PA
Zip	:	17055-4325
Country	:	US
Telephone Number	:	717-972-1100
Fax Number	:	717-975-9981

Provider Business Practice Location Address
First Line	:	1061 PARK DR
Second Line	:
City	:	GREENSBORO
State	:	GA
Zip	:	30642-3465
Country	:	US
Telephone Number	:	706-453-1600
Fax Number	:	706-453-4498

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MICAEL E. TARVIN
Credential	:
Telephone Number	:	717-972-1100

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/31/2010

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