MEDICARE: MRS. MARY ANN SIDES DPT, ATC

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	2194	NE

General Provider Information

NPI Number	:	1477690196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ANN SIDES DPT, ATC

Provider Business Mailing Address
First Line	:	1720 4TH CORSO
Second Line	:
City	:	NEBRASKA CITY
State	:	NE
Zip	:	68410-2633
Country	:	US
Telephone Number	:	402-873-4838
Fax Number	:	402-873-4117

Provider Business Practice Location Address
First Line	:	1240 N 19TH ST
Second Line	:
City	:	NEBRASKA CITY
State	:	NE
Zip	:	68410-1119
Country	:	US
Telephone Number	:	402-873-4838
Fax Number	:	402-873-4117

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/08/2007

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