MEDICARE: MARIE LOUISE TIOSAN MILLEVO 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	045845	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	045845	OTHER		LICENSE

General Provider Information

NPI Number	:	1609521483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE LOUISE TIOSAN MILLEVO PT

Provider Business Mailing Address
First Line	:	510 MAIN ST APT 740
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10044-0171
Country	:	US
Telephone Number	:	201-682-1038
Fax Number	:

Provider Business Practice Location Address
First Line	:	2678 KINGSBRIDGE TER
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10463-7471
Country	:	US
Telephone Number	:	718-796-5800
Fax Number	:

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

Provider Enumeration Date	:	02/19/2022
Last Update Date	:	02/19/2022

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