MEDICARE: KIMBERLY ANN MARVEL 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	225200000X	Physical Therapy Assistant	160001854	IL

General Provider Information

NPI Number	:	1992952899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ANN MARVEL PTA

Provider Business Mailing Address
First Line	:	205 W MAIN ST
Second Line	:
City	:	EWING
State	:	IL
Zip	:	62836-1412
Country	:	US
Telephone Number	:	618-629-2715
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 W MAIN ST
Second Line	:
City	:	EWING
State	:	IL
Zip	:	62836-1412
Country	:	US
Telephone Number	:	618-629-2715
Fax Number	:

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

Provider Enumeration Date	:	08/21/2008
Last Update Date	:	08/21/2008

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Directions to “ KIMBERLY ANN MARVEL PTA” Practice Location

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