MEDICARE: MS. MARY GERALDINE GARDNER PT

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	04587	CT

General Provider Information

NPI Number	:	1952529901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY GERALDINE GARDNER PT

Provider Business Mailing Address
First Line	:	85A FAIRHAVEN RD
Second Line	:
City	:	NIANTIC
State	:	CT
Zip	:	06357-1739
Country	:	US
Telephone Number	:	860-739-8945
Fax Number	:	860-885-6241

Provider Business Practice Location Address
First Line	:	441 SALEM TPKE
Second Line	:
City	:	BOZRAH
State	:	CT
Zip	:	06334-1517
Country	:	US
Telephone Number	:	860-885-6240
Fax Number	:	860-885-6241

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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