MEDICARE: ELAINE RAE PAYNE LMT, PTA

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	174400000X	Specialist	MA30534	FL

General Provider Information

NPI Number	:	1922134055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINE RAE PAYNE LMT, PTA

Provider Business Mailing Address
First Line	:	10406 N 62ND ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33617-3702
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 E FOWLER AVE STE K
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-5400
Country	:	US
Telephone Number	:	813-903-1088
Fax Number	:

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

Provider Enumeration Date	:	02/25/2007
Last Update Date	:	07/08/2007

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