MEDICARE: MRS. ELLEN DEDMON MCCADAMS PTA

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	225200000X	Physical Therapy Assistant	4190	TN

General Provider Information

NPI Number	:	1366679425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELLEN DEDMON MCCADAMS PTA

Provider Business Mailing Address
First Line	:	1000 GREYSTONE SQ
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3580
Country	:	US
Telephone Number	:	731-512-0302
Fax Number	:	731-512-0319

Provider Business Practice Location Address
First Line	:	1000 GREYSTONE SQ
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-3580
Country	:	US
Telephone Number	:	731-512-0302
Fax Number	:	731-512-0319

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

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/16/2009

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