=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053025940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROOSEVELT WARD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2023
-----------------------------------------------------
Last Update Date | 01/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 267 S CHURTON ST
-----------------------------------------------------
City | HILLSBOROUGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27278-2695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-643-4524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6223 DELLO ST
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27712-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------