MEDICARE: MR. JB CONCORDIO GALUTERA III PT

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	PT29656	FL
2	225100000X	Physical Therapist	PT011738	GA

General Provider Information

NPI Number	:	1861894743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JB CONCORDIO GALUTERA III PT

Provider Business Mailing Address
First Line	:	3150 HOWELL MILL RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30327-2108
Country	:	US
Telephone Number	:	404-351-8410
Fax Number	:

Provider Business Practice Location Address
First Line	:	3921 OLD ATLANTA STATION DR SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-1984
Country	:	US
Telephone Number	:	850-766-1672
Fax Number	:

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

Provider Enumeration Date	:	09/22/2014
Last Update Date	:	07/21/2022

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