MEDICARE: MR. JEREMY LEE FORD ATC

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	00-1920	OH

General Provider Information

NPI Number	:	1902879273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEREMY LEE FORD ATC

Provider Business Mailing Address
First Line	:	243 PORTAGE LAKES DR
Second Line	:	APT A
City	:	AKRON
State	:	OH
Zip	:	44319-2392
Country	:	US
Telephone Number	:	330-644-4575
Fax Number	:

Provider Business Practice Location Address
First Line	:	444 N MAIN ST
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44310-3110
Country	:	US
Telephone Number	:	330-379-9488
Fax Number	:	330-379-5511

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	07/08/2007

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