MEDICARE: MR. JACK JOE P.T., M.S.

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	6156-1	NY

General Provider Information

NPI Number	:	1932217767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK JOE P.T., M.S.

Provider Business Mailing Address
First Line	:	20920 26TH AVE
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11360-2441
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3202 BAINBRIDGE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-3947
Country	:	US
Telephone Number	:	718-881-9525
Fax Number	:	718-405-2267

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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