MEDICARE: MR. SERGIO JOSE ALTIZIO 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	40QA00326400	NJ

General Provider Information

NPI Number	:	1538134184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SERGIO JOSE ALTIZIO PT

Provider Business Mailing Address
First Line	:	960 PLEASANT VALLEY WAY
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-1803
Country	:	US
Telephone Number	:	973-243-1177
Fax Number	:	973-243-9077

Provider Business Practice Location Address
First Line	:	960 PLEASANT VALLEY WAY
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-1803
Country	:	US
Telephone Number	:	973-243-1177
Fax Number	:	973-243-9077

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/08/2007

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