MEDICARE: JOHN POWELL RUTHERGLEN PT

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	PT6516	CA

General Provider Information

NPI Number	:	1215921424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN POWELL RUTHERGLEN PT

Provider Business Mailing Address
First Line	:	1 BAYWOOD AVE
Second Line	:	SUITE 1
City	:	SAN MATEO
State	:	CA
Zip	:	94402-1523
Country	:	US
Telephone Number	:	650-348-9400
Fax Number	:	650-348-9402

Provider Business Practice Location Address
First Line	:	1 BAYWOOD AVE
Second Line	:	SUITE 1
City	:	SAN MATEO
State	:	CA
Zip	:	94402-1523
Country	:	US
Telephone Number	:	650-348-9400
Fax Number	:	650-348-9402

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	04/21/2015

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