MEDICARE: JACOB GALLUCCI 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	5501019956	MI

General Provider Information

NPI Number	:	1588241350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB GALLUCCI PT

Provider Business Mailing Address
First Line	:	1773 STAR BATT DR
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-3708
Country	:	US
Telephone Number	:	248-601-9207
Fax Number	:

Provider Business Practice Location Address
First Line	:	1469 N ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-1122
Country	:	US
Telephone Number	:	248-289-5447
Fax Number	:

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

Provider Enumeration Date	:	03/26/2021
Last Update Date	:	03/26/2021

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