MEDICARE: MICHAEL R BIBBO MS, LAT, ATC, CES

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	RTO000092	PA

General Provider Information

NPI Number	:	1225544018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL R BIBBO MS, LAT, ATC, CES

Provider Business Mailing Address
First Line	:	518 SPRING MILL AVE
Second Line	:
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-1950
Country	:	US
Telephone Number	:	610-517-9043
Fax Number	:

Provider Business Practice Location Address
First Line	:	2450 N 54TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-1309
Country	:	US
Telephone Number	:	610-517-9043
Fax Number	:

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

Provider Enumeration Date	:	12/16/2017
Last Update Date	:	12/16/2017

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