MEDICARE: MARY O'BRYAN DEADERICK P.T.

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	8938	TN
2	225100000X	Physical Therapist	31081	FL

General Provider Information

NPI Number	:	1629364831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY O'BRYAN DEADERICK P.T.

Provider Business Mailing Address
First Line	:	2307 S DALE MABRY HWY
Second Line	:	STE F
City	:	TAMPA
State	:	FL
Zip	:	33629-6322
Country	:	US
Telephone Number	:	813-374-9508
Fax Number	:	813-443-5599

Provider Business Practice Location Address
First Line	:	2307 S DALE MABRY HWY
Second Line	:	STE F
City	:	TAMPA
State	:	FL
Zip	:	33629-6322
Country	:	US
Telephone Number	:	813-374-9508
Fax Number	:	813-443-5599

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

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	05/02/2016

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