MEDICARE: MR. HENRY SANTO INTILI FNP

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	363L00000X	Nurse Practitioner	RN123672NP	GA

General Provider Information

NPI Number	:	1851460265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HENRY SANTO INTILI FNP

Provider Business Mailing Address
First Line	:	PO BOX 125
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39818-0125
Country	:	US
Telephone Number	:	229-246-1428
Fax Number	:	229-246-1428

Provider Business Practice Location Address
First Line	:	268 MOCK CEMETERY RD
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39817-6904
Country	:	US
Telephone Number	:	800-841-0858
Fax Number	:	800-841-0858

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/08/2007

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