MEDICARE: DR. MICHAEL JEROME DAVIS JR. 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	225100000X	Physical Therapist	2305204165	VA
2	225100000X	Physical Therapist	PT016539	PA

General Provider Information

NPI Number	:	1194869529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JEROME DAVIS JR. DPT

Provider Business Mailing Address
First Line	:	4967 SHADY GROVE RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-6006
Country	:	US
Telephone Number	:	703-973-4967
Fax Number	:

Provider Business Practice Location Address
First Line	:	2208 IROQUOIS LN
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22043-2506
Country	:	US
Telephone Number	:	703-973-4967
Fax Number	:

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

Provider Enumeration Date	:	02/18/2007
Last Update Date	:	01/02/2013

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