MEDICARE: MR. TRACY DALE MARTIN PT, ATC

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	PT0000002660	TN

General Provider Information

NPI Number	:	1417025289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRACY DALE MARTIN PT, ATC

Provider Business Mailing Address
First Line	:	PO BOX 6167
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37802-6167
Country	:	US
Telephone Number	:	865-977-8007
Fax Number	:	865-977-4072

Provider Business Practice Location Address
First Line	:	829 E LAMAR ALEXANDER PKWY
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37804-5001
Country	:	US
Telephone Number	:	865-977-8282
Fax Number	:	865-982-0143

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	07/08/2007

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