Healthcare Provider Details

I. General information

NPI: 1073907093
Provider Name (Legal Business Name): GREGORY C. EDWARDS PT, DPT, CEEAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 FURYS FERRY RD
MARTINEZ GA
30907-9057
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-9380
  • Fax: 706-650-1896
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018407
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01580400
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017585
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: