Healthcare Provider Details

I. General information

NPI: 1740287259
Provider Name (Legal Business Name): DERRICK ANTONIO BRIDDELL PT, DSC, MS, SCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1496 STILL MEADOW BLVD STE DANDE
SALISBURY MD
21804-7511
US

IV. Provider business mailing address

PO BOX 54
ZEBULON NC
27597-0054
US

V. Phone/Fax

Practice location:
  • Phone: 443-365-2729
  • Fax: 443-365-2730
Mailing address:
  • Phone: 252-367-1118
  • Fax: 800-505-8690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number11098
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberP11098
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP11098
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: