MEDICARE: JOSEPH DEBORTOLI III

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.07939	OH

General Provider Information

NPI Number	:	1518363324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH DEBORTOLI III

Provider Business Mailing Address
First Line	:	7472 W LAKE RD
Second Line	:
City	:	PERRYSBURG
State	:	OH
Zip	:	43551-4565
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	214 S MUNSON RD
Second Line	:
City	:	SWANTON
State	:	OH
Zip	:	43558-1210
Country	:	US
Telephone Number	:	419-464-3899
Fax Number	:

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

Provider Enumeration Date	:	11/06/2014
Last Update Date	:	11/06/2014

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Directions to “ JOSEPH DEBORTOLI III ” Practice Location

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