Healthcare Provider Details

I. General information

NPI: 1679552343
Provider Name (Legal Business Name): WINSTON RYDER WITHERELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TUSKEGEE BLVD 436 MEDICAL GROUP
DOVER AFB DE
19902-5003
US

IV. Provider business mailing address

300 TUSKEGEE BLVD 436 MEDICAL GROUP
DOVER AFB DE
19902-5003
US

V. Phone/Fax

Practice location:
  • Phone: 302-677-2568
  • Fax: 302-677-2540
Mailing address:
  • Phone: 302-677-2568
  • Fax: 302-677-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1593
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: