MEDICARE: STACY J SPURLIN PTA

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	PTA0000002871	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00315004	OTHER	TN	RAILROADMEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	4115301	OTHER	TN	BCBST

General Provider Information

NPI Number	:	1558444166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY J SPURLIN PTA

Provider Business Mailing Address
First Line	:	569 LAKEWOOD VILLAGE RD
Second Line	:
City	:	SPRING CITY
State	:	TN
Zip	:	37381-3712
Country	:	US
Telephone Number	:	423-365-2232
Fax Number	:

Provider Business Practice Location Address
First Line	:	569 LAKEWOOD VILLAGE RD
Second Line	:
City	:	SPRING CITY
State	:	TN
Zip	:	37381-3712
Country	:	US
Telephone Number	:	423-365-2232
Fax Number	:

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/08/2007

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