MEDICARE: MS. ANDREA MARIE DAVIS MSPT

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	05008025A	IN
2	2251X0800X	Orthopedic Physical Therapist	1176298	TX
3	2251X0800X	Orthopedic Physical Therapist	11-04520	KS

General Provider Information

NPI Number	:	1710196449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANDREA MARIE DAVIS MSPT

Provider Business Mailing Address
First Line	:	2419 HART AVE
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-2407
Country	:	US
Telephone Number	:	317-413-8978
Fax Number	:

Provider Business Practice Location Address
First Line	:	1909 N 14TH AVE
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-2364
Country	:	US
Telephone Number	:	620-338-8633
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	04/02/2013

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