MEDICARE: MRS. MARY MAURO-BERTOLO 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	007911-1	NY

General Provider Information

NPI Number	:	1366441248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY MAURO-BERTOLO PT

Provider Business Mailing Address
First Line	:	6221 RTE 31 STE 103
Second Line	:
City	:	CICERO
State	:	NY
Zip	:	13039
Country	:	US
Telephone Number	:	315-699-1009
Fax Number	:	315-699-1094

Provider Business Practice Location Address
First Line	:	6221 RTE 31 STE 103
Second Line	:
City	:	CICERO
State	:	NY
Zip	:	13039
Country	:	US
Telephone Number	:	315-699-1009
Fax Number	:	315-699-1094

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	07/08/2007

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