Healthcare Provider Details

I. General information

NPI: 1558551754
Provider Name (Legal Business Name): THOMAS KELLY COGDELL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PROSPECT AVE
OXFORD NC
27565-2543
US

IV. Provider business mailing address

11310 INVOLUTE PL APT 100
RALEIGH NC
27617-8509
US

V. Phone/Fax

Practice location:
  • Phone: 919-693-1531
  • Fax:
Mailing address:
  • Phone: 919-692-1005
  • Fax: 919-692-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3518
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: