MEDICARE: MAXWELL TAYLOR CERNY

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	3070	MN

General Provider Information

NPI Number	:	1639687957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXWELL TAYLOR CERNY

Provider Business Mailing Address
First Line	:	1120 9TH AVE S APT 103
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-5566
Country	:	US
Telephone Number	:	608-769-5252
Fax Number	:

Provider Business Practice Location Address
First Line	:	1120 9TH AVE S APT 103
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-5566
Country	:	US
Telephone Number	:	608-769-5252
Fax Number	:

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

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	01/22/2018

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