MEDICARE: AMY L PEGG 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	2251P0200X	Pediatric Physical Therapist	05005078A	IN

General Provider Information

NPI Number	:	1710058995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY L PEGG PT

Provider Business Mailing Address
First Line	:	907 NEW HARMONY DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46231-2544
Country	:	US
Telephone Number	:	317-410-8309
Fax Number	:

Provider Business Practice Location Address
First Line	:	907 NEW HARMONY DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46231-2544
Country	:	US
Telephone Number	:	317-410-8309
Fax Number	:

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

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	07/08/2007

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