MEDICARE: SUZANNE BYNUM OTRL

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	225XP0200X	Pediatric Occupational Therapist	4194	NC

General Provider Information

NPI Number	:	1447376090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE BYNUM OTRL

Provider Business Mailing Address
First Line	:	7402 SUN DANCE DR.
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29715
Country	:	US
Telephone Number	:	803-802-0475
Fax Number	:

Provider Business Practice Location Address
First Line	:	7301 CARMEL EXECUTIVE PARK DR
Second Line	:	SUITE 310
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-8251
Country	:	US
Telephone Number	:	704-752-1616
Fax Number	:	704-759-0799

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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