Provider Demographics
NPI:1225035736
Name:BRIDDELL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BRIDDELL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:BRIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DSC, MS, SCS
Authorized Official - Phone:410-251-4467
Mailing Address - Street 1:PO BOX 1651
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-1651
Mailing Address - Country:US
Mailing Address - Phone:410-251-4467
Mailing Address - Fax:
Practice Address - Street 1:1666 WIMBLEDON DR
Practice Address - Street 2:APT 204
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5392
Practice Address - Country:US
Practice Address - Phone:410-251-4467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17958261QP2000X
DEJ1-0001697261QP2000X
NC11098261QP2000X
SC5297261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy