Provider Demographics
NPI:1760677967
Name:FITZGERALD, JOHN C
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CORPORATE DR
Mailing Address - Street 2:STE 400
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:423-238-8923
Mailing Address - Fax:423-954-7399
Practice Address - Street 1:4237 RIVER HILLS DR
Practice Address - Street 2:STE 120
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6444
Practice Address - Country:US
Practice Address - Phone:843-249-5616
Practice Address - Fax:843-249-1843
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6080225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ41108B704Medicare PIN