MEDICARE: CARRIE ANNE MCGILLIS 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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1437199064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE ANNE MCGILLIS ATC

Provider Business Mailing Address
First Line	:	1526 CANTERBURY TRL
Second Line	:	APT. 3B
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-4016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1167 HEALTH PROFESSIONS BUILDING
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48859-0001
Country	:	US
Telephone Number	:	989-774-1341
Fax Number	:

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	07/08/2007

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