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NPI Code Detail

MEDICARE: JILL MARIE LONGFELLOW DPT

MEDICARE: JILL MARIE LONGFELLOW 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
1225100000XPhysical Therapist05009105AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1000000487333OTHERTHERAPIST ANTHEM PROV

General Provider Information

NPI Number : 1407936172
Entity Type Code : Individual
Provider Name (Legal Business Name) : JILL MARIE LONGFELLOW DPT
Provider Business Mailing Address
First Line : 5936 N KEYSTONE AVE
Second Line : SUITE 101
City : INDIANAPOLIS
State : IN
Zip : 46220-2458
Country : US
Telephone Number : 317-257-8340
Fax Number : 317-257-8361
Provider Business Practice Location Address
First Line : 5936 N KEYSTONE AVE
Second Line : SUITE 101
City : INDIANAPOLIS
State : IN
Zip : 46220-2458
Country : US
Telephone Number : 317-257-8340
Fax Number : 317-257-8361
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/17/2006
Last Update Date : 07/08/2007

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Directions to “ JILL MARIE LONGFELLOW DPT” Practice Location

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