Healthcare Provider Details

I. General information

NPI: 1205654381
Provider Name (Legal Business Name): MEREDITH GRACE FIDLER PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MEREDITH GRACE GARDNER

II. Dates (important events)

Enumeration Date: 09/28/2024
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2026 PARKVIEW AVE
KALAMAZOO MI
49008-2834
US

IV. Provider business mailing address

2026 PARKVIEW AVE
KALAMAZOO MI
49008-2834
US

V. Phone/Fax

Practice location:
  • Phone: 269-775-1551
  • Fax: 269-775-1552
Mailing address:
  • Phone: 269-775-1551
  • Fax: 269-775-1552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501303527
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: