MEDICARE: JOSEPH GREGORY FERNICOLA 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	673	AR

General Provider Information

NPI Number	:	1417430562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH GREGORY FERNICOLA PT

Provider Business Mailing Address
First Line	:	11121 N RODNEY PARHAM RD STE 2A
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72212-4158
Country	:	US
Telephone Number	:	501-225-0111
Fax Number	:	501-613-0886

Provider Business Practice Location Address
First Line	:	11121 N RODNEY PARHAM RD STE 2A
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72212-4158
Country	:	US
Telephone Number	:	501-225-0111
Fax Number	:	501-613-0886

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

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	09/13/2018

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