MEDICARE: MR. JASON S GUMPRECHT 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	035275	NY

General Provider Information

NPI Number	:	1457600546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON S GUMPRECHT PT

Provider Business Mailing Address
First Line	:	601 GATES ROAD
Second Line	:	SUITE 3
City	:	VESTAL
State	:	NY
Zip	:	13850-2288
Country	:	US
Telephone Number	:	607-584-7389
Fax Number	:	607-772-1223

Provider Business Practice Location Address
First Line	:	401 MAIN STREET
Second Line	:
City	:	JOHNSON CITY
State	:	NY
Zip	:	13790-2018
Country	:	US
Telephone Number	:	607-798-8800
Fax Number	:	607-798-8801

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

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	09/05/2012

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