MEDICARE: MARIAN ELIZABETH MAURIN 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	PT21754	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y070R	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1669460812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAN ELIZABETH MAURIN P.T.

Provider Business Mailing Address
First Line	:	3820 NORTHDALE BLVD
Second Line	:	STE 302B
City	:	TAMPA
State	:	FL
Zip	:	33624-1863
Country	:	US
Telephone Number	:	813-418-7350
Fax Number	:	813-265-2504

Provider Business Practice Location Address
First Line	:	1501 W CLEVELAND ST
Second Line	:	STE 220
City	:	TAMPA
State	:	FL
Zip	:	33606-1812
Country	:	US
Telephone Number	:	813-805-8105
Fax Number	:	813-254-3055

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	03/13/2012

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