MEDICARE: FAST TRACK SPINE AND SPORTS MEDICINE LLC

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	208100000X	Physical Medicine & Rehabilitation Physician	35-0088642	OH

General Provider Information

NPI Number	:	1639478894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAST TRACK SPINE AND SPORTS MEDICINE LLC

Provider Business Mailing Address
First Line	:	1643 W LANE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3339
Country	:	US
Telephone Number	:	614-775-1503
Fax Number	:	614-317-3001

Provider Business Practice Location Address
First Line	:	1643 W LANE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-3339
Country	:	US
Telephone Number	:	614-775-1503
Fax Number	:	614-775-1503

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. SHELLEY BOONE
Credential	:	MD
Telephone Number	:	412-855-7430

Provider Enumeration Date	:	03/26/2011
Last Update Date	:	11/14/2011

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