MEDICARE: MARILYN JO GREEN 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	PT8132	FL

General Provider Information

NPI Number	:	1841308483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN JO GREEN P.T.

Provider Business Mailing Address
First Line	:	3655 N LAKESIDE VILLAGE DR
Second Line	:
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-3328
Country	:	US
Telephone Number	:	352-746-3472
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 N LECANTO HWY
Second Line	:	SUITE B
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-3548
Country	:	US
Telephone Number	:	352-527-8489
Fax Number	:	352-527-2087

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

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/08/2007

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