MEDICARE: KRISTOPHER JAY VANDERWALL DPT

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	PTH5321	AL
2	225100000X	Physical Therapist	PT.014382	OH

General Provider Information

NPI Number	:	1275797185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTOPHER JAY VANDERWALL DPT

Provider Business Mailing Address
First Line	:	265 CENTER ST
Second Line	:
City	:	SEVILLE
State	:	OH
Zip	:	44273-8864
Country	:	US
Telephone Number	:	330-769-4677
Fax Number	:

Provider Business Practice Location Address
First Line	:	265 CENTER ST
Second Line	:
City	:	SEVILLE
State	:	OH
Zip	:	44273-8864
Country	:	US
Telephone Number	:	330-769-4677
Fax Number	:

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

Provider Enumeration Date	:	07/10/2008
Last Update Date	:	12/17/2013

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