MEDICARE: GLENN R CARLSON MSPT, DPT

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	2251X0800X	Orthopedic Physical Therapist	2111	TN
2	2251X0800X	Orthopedic Physical Therapist	004764	GA

General Provider Information

NPI Number	:	1477640050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN R CARLSON MSPT, DPT

Provider Business Mailing Address
First Line	:	6697 HICKORY BROOK RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-1780
Country	:	US
Telephone Number	:	423-718-4584
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 WALMART DR STE 100
Second Line	:	BENCHMARK PHYSICAL THERAPY
City	:	SODDY DAISY
State	:	TN
Zip	:	37379-5022
Country	:	US
Telephone Number	:	423-332-9490
Fax Number	:

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

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	06/02/2008

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