MEDICARE: JEREMIAH HALES M.S.,L.P.T.

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	174400000X	Specialist	6782	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	77G34HA	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1457327363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMIAH HALES M.S.,L.P.T.

Provider Business Mailing Address
First Line	:	5107 W 98TH ST
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55437-2040
Country	:	US
Telephone Number	:	612-226-5729
Fax Number	:

Provider Business Practice Location Address
First Line	:	5107 W 98TH ST
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55437-2040
Country	:	US
Telephone Number	:	612-226-5729
Fax Number	:

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

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	10/01/2010

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