MEDICARE: ANTONIA M GOELZ P. T.

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		IL

General Provider Information

NPI Number	:	1497899405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIA M GOELZ P. T.

Provider Business Mailing Address
First Line	:	2810 FRANK SCOTT PKWY W
Second Line	:	SUITE 824
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-5007
Country	:	US
Telephone Number	:	618-234-9705
Fax Number	:	618-257-0665

Provider Business Practice Location Address
First Line	:	2810 FRANK SCOTT PKWY W
Second Line	:	SUITE 824
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-5007
Country	:	US
Telephone Number	:	618-234-9705
Fax Number	:	618-257-0665

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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