MEDICARE: MID-PENINSULA HAND REHABILITATION & ERGONOMICS

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	261QP2000X	Physical Therapy Clinic/Center	521	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	FD906A	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1558659383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-PENINSULA HAND REHABILITATION & ERGONOMICS

Provider Business Mailing Address
First Line	:	1155 UNIVERSITY DR
Second Line	:	BUILDING 1
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4431
Country	:	US
Telephone Number	:	650-245-2844
Fax Number	:	650-712-0419

Provider Business Practice Location Address
First Line	:	1155 UNIVERSITY DR
Second Line	:	BUILDING 1
City	:	MENLO PARK
State	:	CA
Zip	:	94025-4431
Country	:	US
Telephone Number	:	650-245-2844
Fax Number	:	650-712-0419

Authorized Official
Title or Position	:	CEO
Name	:	LORI KAY STOTKO
Credential	:	OTR CHT
Telephone Number	:	650-245-2844

Provider Enumeration Date	:	07/14/2011
Last Update Date	:	08/29/2011

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