MEDICARE: MARTHA BLAIR GWALTNEY PT, 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	P13736	NC

General Provider Information

NPI Number	:	1912258674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA BLAIR GWALTNEY PT, DPT

Provider Business Mailing Address
First Line	:	2122 YORK RD STE 300
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1925
Country	:	US
Telephone Number	:	570-550-0168
Fax Number	:	410-648-4878

Provider Business Practice Location Address
First Line	:	1317 N BRIGHTLEAF BLVD STE A
Second Line	:
City	:	SMITHFIELD
State	:	NC
Zip	:	27577-7267
Country	:	US
Telephone Number	:	919-300-5040
Fax Number	:

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

Provider Enumeration Date	:	09/20/2012
Last Update Date	:	06/10/2024

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