MEDICARE: DR. ALEXANDER FORMOLOW D.P.T.

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	40QA01092200	NJ

General Provider Information

NPI Number	:	1326115635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDER FORMOLOW D.P.T.

Provider Business Mailing Address
First Line	:	703 BEGONIA CT
Second Line	:
City	:	JACKSON
State	:	NJ
Zip	:	08527-4176
Country	:	US
Telephone Number	:	732-939-1360
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 SUNSET RD
Second Line	:	SUITE 5A AND B
City	:	WILLINGBORO
State	:	NJ
Zip	:	08046-1126
Country	:	US
Telephone Number	:	609-835-4801
Fax Number	:

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	03/06/2009

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