MEDICARE: MS. MARY GOLOB PT DPT

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	1037	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	079WH	OTHER		BCBS

General Provider Information

NPI Number	:	1841217304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY GOLOB PT DPT

Provider Business Mailing Address
First Line	:	1431 FUTCH CREEK RD
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28411-9373
Country	:	US
Telephone Number	:	910-686-2613
Fax Number	:

Provider Business Practice Location Address
First Line	:	8044 MARKET ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28411-9384
Country	:	US
Telephone Number	:	910-686-6440
Fax Number	:	910-686-6441

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	01/31/2011

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