MEDICARE: MS. CYNTHIA GUSTAFSON RPT

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	3705	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y65881	OTHER	MA	BLUE CROSS
2	705278	OTHER	MA	TUFTS HEALTH PLAN
3	6400066	OTHER	MA	UNITED HEALTHCARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447242029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CYNTHIA GUSTAFSON RPT

Provider Business Mailing Address
First Line	:	315 CENTRAL ST
Second Line	:
City	:	SAUGUS
State	:	MA
Zip	:	01906-2342
Country	:	US
Telephone Number	:	781-231-2292
Fax Number	:	781-231-2292

Provider Business Practice Location Address
First Line	:	315 CENTRAL ST
Second Line	:
City	:	SAUGUS
State	:	MA
Zip	:	01906-2342
Country	:	US
Telephone Number	:	781-231-2292
Fax Number	:	781-231-2292

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/09/2007

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