Basic Information
| Provider Information | |||||||||
| NPI: | 1841239605 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRONSON | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 HWY 81 S | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300523918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705540665 | ||||||||
| FaxNumber: | 7705540685 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 CONOWINGO RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BEL AIR | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210141809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104202257 | ||||||||
| FaxNumber: | 4104202267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT012971L | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 19783 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 468M | 01 | MD | MEDICARE GROUP PTAN | OTHER |