MEDICARE: DR. BERNARD ETHERLY D.C.

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	111NS0005X	Sports Physician Chiropractor	0104555772	VA

General Provider Information

NPI Number	:	1285784975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BERNARD ETHERLY D.C.

Provider Business Mailing Address
First Line	:	48 NEW YORK AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20001-1257
Country	:	US
Telephone Number	:	202-898-0030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 26TH RD S
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22206-2818
Country	:	US
Telephone Number	:	703-486-2225
Fax Number	:

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

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/08/2007

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