MEDICARE: WIM LIPPERS

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT003179	OTHER	GA	LICENSE #

General Provider Information

NPI Number	:	1275642498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WIM LIPPERS

Provider Business Mailing Address
First Line	:	3254 EAGLE WATCH DR
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-6861
Country	:	US
Telephone Number	:	770-924-5487
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 ERNEST W BARRETT PKWY NW
Second Line	:	STE 58
City	:	KENNESAW
State	:	GA
Zip	:	30144-4918
Country	:	US
Telephone Number	:	770-425-2440
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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Directions to “ WIM LIPPERS ” Practice Location

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