MEDICARE: BENJAMIN DOUGLASS 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	225100000X	Physical Therapist	PT-3563	ID

General Provider Information

NPI Number	:	1508277120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN DOUGLASS DPT

Provider Business Mailing Address
First Line	:	1560 S CAROL ST
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1839
Country	:	US
Telephone Number	:	208-288-1155
Fax Number	:	208-288-0424

Provider Business Practice Location Address
First Line	:	120 E PINE ST
Second Line	:
City	:	CALDWELL
State	:	ID
Zip	:	83605-4836
Country	:	US
Telephone Number	:	208-454-5142
Fax Number	:	208-454-5148

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

Provider Enumeration Date	:	05/16/2014
Last Update Date	:	05/16/2014

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