MEDICARE: DERWIN BARNARD CANTRELL PT, DPT

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	PTH9945	AL

General Provider Information

NPI Number	:	1689289191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERWIN BARNARD CANTRELL PT, DPT

Provider Business Mailing Address
First Line	:	1200 CORPORATE DR STE 400
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35242-5424
Country	:	US
Telephone Number	:	423-238-7217
Fax Number	:

Provider Business Practice Location Address
First Line	:	1622 CHURCH AVE SE
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3200
Country	:	US
Telephone Number	:	256-365-2792
Fax Number	:	256-937-7457

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

Provider Enumeration Date	:	09/11/2020
Last Update Date	:	09/11/2020

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