MEDICARE: MR. TYLER LEE 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	PT005238	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	116558	OTHER	GA	MEDICARE

General Provider Information

NPI Number	:	1508873746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER LEE PT

Provider Business Mailing Address
First Line	:	PO BOX 523
Second Line	:
City	:	CAIRO
State	:	GA
Zip	:	39828-2605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 MARTIN LUTHER KING JR AVE SW
Second Line	:
City	:	CAIRO
State	:	GA
Zip	:	39828-2605
Country	:	US
Telephone Number	:	229-377-0882
Fax Number	:	229-377-0883

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	12/19/2007

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