MEDICARE: MR. JEFFREY LYNN REALE 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	PT 004856	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000134699	OTHER	OH	ANTHEM BC/BS

General Provider Information

NPI Number	:	1538182662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY LYNN REALE PT

Provider Business Mailing Address
First Line	:	4645 BELPAR ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-3602
Country	:	US
Telephone Number	:	330-493-4210
Fax Number	:	330-493-4744

Provider Business Practice Location Address
First Line	:	850 W MAPLE ST
Second Line	:
City	:	HARTVILLE
State	:	OH
Zip	:	44632-9668
Country	:	US
Telephone Number	:	330-877-3488
Fax Number	:	330-877-4147

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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