Provider Demographics
NPI:1659582906
Name:FIDIS, MARCIAL NELSON (LPT)
Entity Type:Individual
Prefix:MR
First Name:MARCIAL
Middle Name:NELSON
Last Name:FIDIS
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BRIARBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-3703
Mailing Address - Country:US
Mailing Address - Phone:828-669-4148
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-6418
Practice Address - Country:US
Practice Address - Phone:828-894-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist