MEDICARE: MR. KEVIN T EISELE CERTIFIED PEDORTHIST

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	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1750344669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN T EISELE CERTIFIED PEDORTHIST

Provider Business Mailing Address
First Line	:	PO BOX 631
Second Line	:
City	:	MILES CITY
State	:	MT
Zip	:	59301-0631
Country	:	US
Telephone Number	:	406-234-1895
Fax Number	:	406-234-1895

Provider Business Practice Location Address
First Line	:	2713 GUM FLAT RD
Second Line	:
City	:	MILES CITY
State	:	MT
Zip	:	59301-2893
Country	:	US
Telephone Number	:	406-234-1895
Fax Number	:	406-234-1895

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

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	12/05/2007

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