MEDICARE: ANDREW J TABER 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	10026	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10026-024	OTHER	WI	LICENSE

General Provider Information

NPI Number	:	1457336992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW J TABER PT

Provider Business Mailing Address
First Line	:	2105 E ENTERPRISE AVE STE 113
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54913-7862
Country	:	US
Telephone Number	:	920-560-1147
Fax Number	:	920-560-1197

Provider Business Practice Location Address
First Line	:	2223 LIME KILN RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-6213
Country	:	US
Telephone Number	:	920-560-1147
Fax Number	:	920-560-1197

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	07/11/2025

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Directions to “ ANDREW J TABER PT” Practice Location

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