MEDICARE: MS. JUSTINE MARY ANTON GILLEN 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	002869	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2266611	OTHER		FIRST HEALTH
2	7820314	OTHER		AETNA
3	080002869CT01	OTHER	CT	ANTHEM B/C B/S

General Provider Information

NPI Number	:	1548326879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUSTINE MARY ANTON GILLEN PT

Provider Business Mailing Address
First Line	:	500 E MAIN ST
Second Line	:	SUITE 310
City	:	BRANFORD
State	:	CT
Zip	:	06405-2911
Country	:	US
Telephone Number	:	203-315-7727
Fax Number	:	203-315-7757

Provider Business Practice Location Address
First Line	:	500 E MAIN ST
Second Line	:	SUITE 310
City	:	BRANFORD
State	:	CT
Zip	:	06405-2911
Country	:	US
Telephone Number	:	203-315-7727
Fax Number	:	203-315-7757

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

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	03/01/2016

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