MEDICARE: MARY JANE VACIRCA MS, 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	022800	NY

General Provider Information

NPI Number	:	1235445370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JANE VACIRCA MS, PT

Provider Business Mailing Address
First Line	:	123 BARNUM AVE
Second Line	:
City	:	PORT JEFFERSON
State	:	NY
Zip	:	11777-1621
Country	:	US
Telephone Number	:	631-748-9519
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 BARNUM AVE
Second Line	:
City	:	PORT JEFFERSON
State	:	NY
Zip	:	11777-1621
Country	:	US
Telephone Number	:	631-748-9519
Fax Number	:

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

Provider Enumeration Date	:	08/26/2010
Last Update Date	:	08/26/2010

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