MEDICARE: TYLER BURCHAM DPT

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	1738	ND
2	174400000X	Specialist	PT2542	ID
3	225100000X	Physical Therapist	PT-2542	ID

General Provider Information

NPI Number	:	1912138231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER BURCHAM DPT

Provider Business Mailing Address
First Line	:	1560 S CAROL ST
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1839
Country	:	US
Telephone Number	:	208-288-1155
Fax Number	:	208-288-0424

Provider Business Practice Location Address
First Line	:	3170 43RD ST S
Second Line	:	SUITE 101
City	:	FARGO
State	:	ND
Zip	:	58104-8908
Country	:	US
Telephone Number	:	701-277-8448
Fax Number	:	701-277-8668

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

Provider Enumeration Date	:	08/04/2009
Last Update Date	:	06/06/2013

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