Healthcare Provider Details

I. General information

NPI: 1376643882
Provider Name (Legal Business Name): RUSSELL D GANNON MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 GADSDEN HWY SUITE A
BIRMINGHAM AL
35235-2501
US

IV. Provider business mailing address

548 TWIN BRANCH DR
BIRMINGHAM AL
35226-2342
US

V. Phone/Fax

Practice location:
  • Phone: 205-833-0881
  • Fax: 205-833-1190
Mailing address:
  • Phone: 205-823-4236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPTH3502
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: