MEDICARE: MR. ERNEST J GAMBLE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40QA010358900	OTHER	NJ	LICENSE #

General Provider Information

NPI Number	:	1467560748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERNEST J GAMBLE PT

Provider Business Mailing Address
First Line	:	890 W BAY AVE
Second Line	:	SUITE A
City	:	BARNEGAT
State	:	NJ
Zip	:	08005-2150
Country	:	US
Telephone Number	:	609-698-1073
Fax Number	:	609-698-1473

Provider Business Practice Location Address
First Line	:	890 W BAY AVE
Second Line	:	SUITE A
City	:	BARNEGAT
State	:	NJ
Zip	:	08005-2150
Country	:	US
Telephone Number	:	609-698-1073
Fax Number	:	609-698-1473

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

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	12/08/2007

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