MEDICARE: STEPHEN J INGERSOLL II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	P17926	NC

General Provider Information

NPI Number	:	1629562301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN J INGERSOLL II

Provider Business Mailing Address
First Line	:	4215 WATERBURY DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3044
Country	:	US
Telephone Number	:	980-422-8992
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 LAMAR AVE STE 101
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2436
Country	:	US
Telephone Number	:	980-422-8992
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2018
Last Update Date	:	01/06/2020

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