MEDICARE: MR. WALTER K. CLEARY P.T.

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	1263	NC
2	225100000X	Physical Therapist	966	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	640224	OTHER	KY	UNITED HEALTHCARE
2	00000004875	OTHER	KY	ANTHEM

General Provider Information

NPI Number	:	1841294899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER K. CLEARY P.T.

Provider Business Mailing Address
First Line	:	1480 18TH ST
Second Line	:
City	:	CORBIN
State	:	KY
Zip	:	40701-2721
Country	:	US
Telephone Number	:	606-528-0891
Fax Number	:	606-528-3449

Provider Business Practice Location Address
First Line	:	1480 18TH ST
Second Line	:
City	:	CORBIN
State	:	KY
Zip	:	40701-2721
Country	:	US
Telephone Number	:	606-528-0870
Fax Number	:	606-528-3449

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	01/29/2008

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