Healthcare Provider Details

I. General information

NPI: 1235556721
Provider Name (Legal Business Name): GREGORY CHARLES PANCAKE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4446 WASHINGTON RD STE 8
EVANS GA
30809-6361
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 706-869-3352
  • Fax: 706-869-3299
Mailing address:
  • Phone: 423-238-2717
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14739
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT014742
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: