MEDICARE: SMR BANYAN TREE, INC.

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1255361556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMR BANYAN TREE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1245
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-5245
Country	:	US
Telephone Number	:	724-465-3496
Fax Number	:	215-413-4682

Provider Business Practice Location Address
First Line	:	3262 CENTER RD
Second Line	:	SUITE B
City	:	POLAND
State	:	OH
Zip	:	44514-2290
Country	:	US
Telephone Number	:	330-707-1190
Fax Number	:	330-707-1191

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER
Name	:	MRS. JAYNE FLECK POOL
Credential	:
Telephone Number	:	469-467-8705

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	06/28/2010

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