MEDICARE: PHILIP JOSEPH BRAZALOVICH JR. ATC

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	2255A2300X	Athletic Trainer	001143	CT
2	2255A2300X	Athletic Trainer	AT005382	OH

General Provider Information

NPI Number	:	1710411491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP JOSEPH BRAZALOVICH JR. ATC

Provider Business Mailing Address
First Line	:	96 TALCOTT RD
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-2919
Country	:	US
Telephone Number	:	860-712-8466
Fax Number	:

Provider Business Practice Location Address
First Line	:	1824 PARKFORD LN
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-7084
Country	:	US
Telephone Number	:	860-712-8466
Fax Number	:

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

Provider Enumeration Date	:	04/19/2017
Last Update Date	:	08/06/2020

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