MEDICARE: MR. SHERRY LYNNE WEATHERFORD LMT

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	174400000X	Specialist	MA16326	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C7345	OTHER	FL	PIN BLUECROSS BLUE SHILED

General Provider Information

NPI Number	:	1710026497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHERRY LYNNE WEATHERFORD LMT

Provider Business Mailing Address
First Line	:	6840 W AVOCADO ST
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-5680
Country	:	US
Telephone Number	:	352-220-0167
Fax Number	:	352-795-4732

Provider Business Practice Location Address
First Line	:	9030 W FORT ISLAND TRL BLDG 10
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-2412
Country	:	US
Telephone Number	:	352-220-0167
Fax Number	:	352-795-4732

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

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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Directions to “ MR. SHERRY LYNNE WEATHERFORD LMT” Practice Location

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