MEDICARE: DECATUR PHYSICAL THERAPY & SPORTS MEDICINE

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	261QP2000X	Physical Therapy Clinic/Center	2841	GA

General Provider Information

NPI Number	:	1962841064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DECATUR PHYSICAL THERAPY & SPORTS MEDICINE

Provider Business Mailing Address
First Line	:	487 WINN WAY STE 201
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1728
Country	:	US
Telephone Number	:	404-297-9315
Fax Number	:	404-297-2741

Provider Business Practice Location Address
First Line	:	487 WINN WAY STE 201
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1728
Country	:	US
Telephone Number	:	404-297-9315
Fax Number	:	404-297-2741

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	CECIL M ANDERSON III
Credential	:	PT
Telephone Number	:	404-297-9315

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	06/21/2013

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Directions to “DECATUR PHYSICAL THERAPY & SPORTS MEDICINE ” Practice Location

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