MEDICARE: JONATHAN RYAN KRETSCH 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	26776	MD

General Provider Information

NPI Number	:	1922511872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN RYAN KRETSCH DPT

Provider Business Mailing Address
First Line	:	3455 HIGHWAY 81 SOUTH
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-3918
Country	:	US
Telephone Number	:	770-554-0665
Fax Number	:	770-554-0685

Provider Business Practice Location Address
First Line	:	7939 HONEYGO BLVD STE 131
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21236-5905
Country	:	US
Telephone Number	:	410-931-2738
Fax Number	:	410-931-2739

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

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	11/14/2017

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