MEDICARE: MR. MARK DOUGLAS MOTTICE 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	PT 003209	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000134718	OTHER	OH	ANTHEM BC/BS
2	299522343001	OTHER	OH	MEDICAL MUTUAL OF OHIO

General Provider Information

NPI Number	:	1679594824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK DOUGLAS MOTTICE PT

Provider Business Mailing Address
First Line	:	4645 BELPAR ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-3602
Country	:	US
Telephone Number	:	330-493-4210
Fax Number	:	330-493-4744

Provider Business Practice Location Address
First Line	:	4645 BELPAR ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-3602
Country	:	US
Telephone Number	:	330-493-4210
Fax Number	:	330-493-4744

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

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. MARK DOUGLAS MOTTICE PT” Practice Location

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