MEDICARE: TOMMY CARL AMBURGEY PTA

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	225200000X	Physical Therapy Assistant	A01863	KY

General Provider Information

NPI Number	:	1184137713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOMMY CARL AMBURGEY PTA

Provider Business Mailing Address
First Line	:	1075 E 4TH ST STE 2
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-2528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 E 4TH ST STE 2
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-2528
Country	:	US
Telephone Number	:	606-330-0223
Fax Number	:

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

Provider Enumeration Date	:	11/06/2017
Last Update Date	:	11/06/2017

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