MEDICARE: MR. ANDREW VIRGIL PTA

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	225200000X	Physical Therapy Assistant	PTA.06691	OH

General Provider Information

NPI Number	:	1518153451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREW VIRGIL PTA

Provider Business Mailing Address
First Line	:	180 W COMO AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43202-1028
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 W COMO AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43202-1028
Country	:	US
Telephone Number	:	614-425-3879
Fax Number	:

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

Provider Enumeration Date	:	09/24/2007
Last Update Date	:	09/24/2007

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