MEDICARE: MARYBETH TAYLOR

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

General Provider Information

NPI Number	:	1194368985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYBETH TAYLOR

Provider Business Mailing Address
First Line	:	31885 ALLISON DR
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-4505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	261 MACK AVE # 215
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2417
Country	:	US
Telephone Number	:	616-540-2829
Fax Number	:

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

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	10/24/2019

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