MEDICARE: SARAH G FORD 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	PT006269	GA
2	2255A2300X	Athletic Trainer	ATC020202200	GA

General Provider Information

NPI Number	:	1699771899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH G FORD PT

Provider Business Mailing Address
First Line	:	5300 HICKORY PARK DR
Second Line	:	SUITE 110
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-2629
Country	:	US
Telephone Number	:	804-756-8495
Fax Number	:	804-270-7756

Provider Business Practice Location Address
First Line	:	13575 HEATHCOTE BLVD
Second Line	:
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-6660
Country	:	US
Telephone Number	:	571-261-9900
Fax Number	:	571-261-9908

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	10/07/2015

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Directions to “ SARAH G FORD PT” Practice Location

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