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NPI Code Detail

MEDICARE: GLENN EUGENE KERSHAW JR. PTA

MEDICARE: GLENN EUGENE KERSHAW JR. PTA
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
1225200000XPhysical Therapy Assistant03121OH

General Provider Information

NPI Number : 1780836700
Entity Type Code : Individual
Provider Name (Legal Business Name) : GLENN EUGENE KERSHAW JR. PTA
Provider Business Mailing Address
First Line : 9002 MENTOR AVE
Second Line :
City : MENTOR
State : OH
Zip : 44060-6302
Country : US
Telephone Number : 440-266-1901
Fax Number : 440-266-1902
Provider Business Practice Location Address
First Line : 9002 MENTOR AVE
Second Line :
City : MENTOR
State : OH
Zip : 44060-6302
Country : US
Telephone Number : 440-266-1901
Fax Number : 440-266-1902
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/22/2008
Last Update Date : 10/22/2008

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