Provider Demographics
NPI:1942480827
Name:IDELL, GREGORY CHADWICK (PT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:CHADWICK
Last Name:IDELL
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 1:1759 NE 40TH PL
Mailing Address - Street 2:APT 602
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-9202
Mailing Address - Country:US
Mailing Address - Phone:561-271-2142
Mailing Address - Fax:
Practice Address - Street 1:1759 NE 40TH PL
Practice Address - Street 2:APT 602
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-9202
Practice Address - Country:US
Practice Address - Phone:561-271-2142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6235Medicare PIN