MEDICARE: MS. MARJORIE JEAN ALBOHM 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	36000100A	IN

General Provider Information

NPI Number	:	1578565982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARJORIE JEAN ALBOHM ATC

Provider Business Mailing Address
First Line	:	4159 LAKEWOOD TRL
Second Line	:
City	:	CLAYTON
State	:	IN
Zip	:	46118-9373
Country	:	US
Telephone Number	:	317-802-2880
Fax Number	:	317-802-2170

Provider Business Practice Location Address
First Line	:	8450 NORTHWEST BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46278-1381
Country	:	US
Telephone Number	:	317-802-2880
Fax Number	:	317-802-2170

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	07/08/2007

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