MEDICARE: MR. JOHN THOMAS GIOVENGO IV MS,ATC,PTA

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	225200000X	Physical Therapy Assistant
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1669659124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN THOMAS GIOVENGO IV MS,ATC,PTA

Provider Business Mailing Address
First Line	:	408 WATER ST
Second Line	:
City	:	BENWOOD
State	:	WV
Zip	:	26031-1124
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 WATER ST
Second Line	:
City	:	BENWOOD
State	:	WV
Zip	:	26031-1124
Country	:	US
Telephone Number	:	304-233-9091
Fax Number	:

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

Provider Enumeration Date	:	01/28/2008
Last Update Date	:	01/28/2008

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