MEDICARE: MRS. CHERYL L TIBESAR 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	225100000X	Physical Therapist	1544	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HP41170	OTHER	MN	HEALTH PARTNERS
2	6403620	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1770595159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHERYL L TIBESAR PT

Provider Business Mailing Address
First Line	:	4330 CEDAR LAKE RD S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-3700
Country	:	US
Telephone Number	:	952-381-3434
Fax Number	:	952-377-1430

Provider Business Practice Location Address
First Line	:	4330 CEDAR LAKE RD S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-3700
Country	:	US
Telephone Number	:	952-381-3434
Fax Number	:	952-377-1430

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	08/14/2007

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