MEDICARE: MR. ROBERT J. SHRINER JR. ATC

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	2255A2300X	Athletic Trainer	36000142	IN

General Provider Information

NPI Number	:	1568490043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT J. SHRINER JR. ATC

Provider Business Mailing Address
First Line	:	1202 LINCOLN WAY E
Second Line	:
City	:	MISHAWAKA
State	:	IN
Zip	:	46544-2716
Country	:	US
Telephone Number	:	574-254-7320
Fax Number	:	574-254-7482

Provider Business Practice Location Address
First Line	:	1202 LINCOLN WAY E
Second Line	:
City	:	MISHAWAKA
State	:	IN
Zip	:	46544-2716
Country	:	US
Telephone Number	:	574-254-7320
Fax Number	:	574-254-7482

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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