MEDICARE: FADEL TAAZIEH DPT, ATC

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	PT30000	FL
2	2255A2300X	Athletic Trainer	PT30000	FL

General Provider Information

NPI Number	:	1659760189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FADEL TAAZIEH DPT, ATC

Provider Business Mailing Address
First Line	:	PO BOX 40767
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32203-0767
Country	:	US
Telephone Number	:	904-376-3707
Fax Number	:	904-391-5807

Provider Business Practice Location Address
First Line	:	7740 POINT MEADOWS DR STE 1
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9180
Country	:	US
Telephone Number	:	904-564-9594
Fax Number	:	904-564-9687

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

Provider Enumeration Date	:	01/21/2015
Last Update Date	:	02/06/2015

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