MEDICARE: MS. KATHLEEN MARIE WASKEWICZ 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	8633	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q15741	OTHER	NY	MEDICARE PART B PROGRAM

General Provider Information

NPI Number	:	1679751531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN MARIE WASKEWICZ PT

Provider Business Mailing Address
First Line	:	24 BEACH AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2102
Country	:	US
Telephone Number	:	631-474-4578
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 BEACH AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2102
Country	:	US
Telephone Number	:	631-474-4578
Fax Number	:

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

Provider Enumeration Date	:	02/03/2008
Last Update Date	:	02/03/2008

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