MEDICARE: MR. DONALD M CARLSON 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	589	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	589	OTHER	MN	MN BD OF PT

General Provider Information

NPI Number	:	1902875040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD M CARLSON PT

Provider Business Mailing Address
First Line	:	7933 CO 65 NE
Second Line	:
City	:	DEER RIVER
State	:	MN
Zip	:	56636
Country	:	US
Telephone Number	:	218-566-2288
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 GOLF COURSE RD
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3526
Country	:	US
Telephone Number	:	218-327-7257
Fax Number	:	218-327-1585

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/08/2007

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