MEDICARE: MS. MARY TEW LONG M.A.T., ATC, LAT

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	061	AL

General Provider Information

NPI Number	:	1780613091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY TEW LONG M.A.T., ATC, LAT

Provider Business Mailing Address
First Line	:	13717 RANDA PKWY
Second Line	:
City	:	NORTHPORT
State	:	AL
Zip	:	35475-3473
Country	:	US
Telephone Number	:	205-330-0998
Fax Number	:

Provider Business Practice Location Address
First Line	:	1325 MCFARLAND BLVD
Second Line	:	THE SPORTS AND MEDICINE COMPLEX
City	:	NORTHPORT
State	:	AL
Zip	:	35476-3270
Country	:	US
Telephone Number	:	205-333-4778
Fax Number	:	205-333-4776

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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