MEDICARE: MARY JANE BOULEY 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	016481	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P010016481	OTHER	NY	BLUE CHOICE
2	103351FT	OTHER	NY	PREFERRED CARE
3	7024316	OTHER	NY	AETNA
4	P011016481	OTHER	NY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1447220140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JANE BOULEY PT

Provider Business Mailing Address
First Line	:	37 N UNION STREET
Second Line	:
City	:	SPENCERPORT
State	:	NY
Zip	:	14559
Country	:	US
Telephone Number	:	585-349-2860
Fax Number	:	585-349-2995

Provider Business Practice Location Address
First Line	:	37 N UNION STREET
Second Line	:
City	:	SPENCERPORT
State	:	NY
Zip	:	14559
Country	:	US
Telephone Number	:	585-349-2860
Fax Number	:	585-349-2995

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	08/20/2008

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Directions to “ MARY JANE BOULEY PT” Practice Location

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