MEDICARE: TYE MARR 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	PT007416	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11724391	OTHER	GA	CAQH

General Provider Information

NPI Number	:	1689605958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYE MARR PT

Provider Business Mailing Address
First Line	:	80 TECHNACENTER DR
Second Line	:	SUITE 300
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-6028
Country	:	US
Telephone Number	:	334-625-5795
Fax Number	:	334-396-4905

Provider Business Practice Location Address
First Line	:	4900 IVEY RD NW
Second Line	:	SUITE 1001
City	:	ACWORTH
State	:	GA
Zip	:	30101-4001
Country	:	US
Telephone Number	:	770-917-0924
Fax Number	:	770-917-0926

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	03/16/2016

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Directions to “ TYE MARR PT” Practice Location

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