Provider Demographics
NPI:1982091450
Name:DUEITT, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:DUEITT
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 1:251 JOHNSTON ST SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2515
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:5643 SERMON RD S
Practice Address - Street 2:
Practice Address - City:THEODORE
Practice Address - State:AL
Practice Address - Zip Code:36582-3608
Practice Address - Country:US
Practice Address - Phone:251-660-1505
Practice Address - Fax:251-660-9007
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917620Medicaid
AL1003819608OtherGROUP NPI
AL529917620Medicaid