MEDICARE: MR. MICHAEL ANTHONY PRYBICIEN A.T.C. EMTB, C.S.C.S

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	25MT00062100	NJ
2	2255A2300X	Athletic Trainer	RT001246A	PA
3	146N00000X	Basic Emergency Medical Technician		NJ

General Provider Information

NPI Number	:	1891767901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL ANTHONY PRYBICIEN A.T.C. EMTB, C.S.C.S

Provider Business Mailing Address
First Line	:	102 PATRICIA PL
Second Line	:
City	:	CLIFTON
State	:	NJ
Zip	:	07012-1855
Country	:	US
Telephone Number	:	973-594-9651
Fax Number	:	973-571-4170

Provider Business Practice Location Address
First Line	:	799 BLOOMFIELD AVENUE
Second Line	:	SUITE 304
City	:	VERONA
State	:	NJ
Zip	:	07044-1301
Country	:	US
Telephone Number	:	973-571-0001
Fax Number	:	973-571-4170

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	06/27/2012

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