MEDICARE: MR. ROBERT ELLSWORTH DAVIS II 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	001310	WV

General Provider Information

NPI Number	:	1255529822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT ELLSWORTH DAVIS II PT

Provider Business Mailing Address
First Line	:	115 ALBANY LN
Second Line	:
City	:	MOUNT HOPE
State	:	WV
Zip	:	25880-9648
Country	:	US
Telephone Number	:	304-253-3780
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 ALBANY LN
Second Line	:
City	:	MOUNT HOPE
State	:	WV
Zip	:	25880-9648
Country	:	US
Telephone Number	:	304-253-3780
Fax Number	:

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

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/09/2007

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