MEDICARE: TOM THOMAS ATC, EMT

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	25MT00128900	NJ

General Provider Information

NPI Number	:	1841359767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOM THOMAS ATC, EMT

Provider Business Mailing Address
First Line	:	39 ORCHARD PL
Second Line	:
City	:	MAYWOOD
State	:	NJ
Zip	:	07607-1835
Country	:	US
Telephone Number	:	201-314-2481
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 ORCHARD PL
Second Line	:
City	:	MAYWOOD
State	:	NJ
Zip	:	07607-1835
Country	:	US
Telephone Number	:	201-314-2481
Fax Number	:

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/08/2007

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