MEDICARE: TJ MEDICAL LLC

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1861788036
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TJ MEDICAL LLC

Provider Business Mailing Address
First Line	:	1905 S 25TH ST
Second Line	:	SUITE 100
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4739
Country	:	US
Telephone Number	:	772-467-9083
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 S 25TH ST
Second Line	:	SUITE 100
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4739
Country	:	US
Telephone Number	:	772-467-9083
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. PETER BLAKE
Credential	:
Telephone Number	:	772-467-9083

Provider Enumeration Date	:	06/25/2011
Last Update Date	:	06/25/2011

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