Provider Demographics
NPI:1114082013
Name:GENTRY, BRIAN MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GENTRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 LAKE BOONE TRAIL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7511
Mailing Address - Country:US
Mailing Address - Phone:919-781-4434
Mailing Address - Fax:919-781-5851
Practice Address - Street 1:4201 LAKE BOONE TRAIL
Practice Address - Street 2:SUITE 4
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7511
Practice Address - Country:US
Practice Address - Phone:919-781-4434
Practice Address - Fax:919-781-5851
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6400040OtherUNITED HEALTHCARE
E4463OtherMEDCOST
NC7211783Medicaid
NC079R4OtherBCBS
7187712OtherAETNA
NC8300041KMedicaid