MEDICARE: MRS. TESSA K POTERALSKI 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	PT5999	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT 5999	OTHER	TN	PT

General Provider Information

NPI Number	:	1659402683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TESSA K POTERALSKI PT

Provider Business Mailing Address
First Line	:	74 BOXWOOD DR
Second Line	:
City	:	RINGGOLD
State	:	GA
Zip	:	30736-2892
Country	:	US
Telephone Number	:	706-935-5813
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 FINCHER AVE
Second Line	:
City	:	EAST RIDGE
State	:	TN
Zip	:	37412-4204
Country	:	US
Telephone Number	:	423-894-1254
Fax Number	:

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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