MEDICARE: ELOISE PENKA DORAN P.T.

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	11-01132	KS

General Provider Information

NPI Number	:	1538384748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELOISE PENKA DORAN P.T.

Provider Business Mailing Address
First Line	:	PO BOX 51
Second Line	:
City	:	SAINT JOHN
State	:	KS
Zip	:	67576-0051
Country	:	US
Telephone Number	:	620-549-6492
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 N BROADWAY ST
Second Line	:
City	:	SAINT JOHN
State	:	KS
Zip	:	67576-1833
Country	:	US
Telephone Number	:	620-549-6492
Fax Number	:

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

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/08/2007

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