=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114985249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT EMERSON DUVALL PT DHSC MMSC OCS FAA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 11/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2138 SCENIC HWY STE B
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-979-1400
-----------------------------------------------------
Fax | 770-978-0974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2138 SCENIC HWY STE B
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-979-1400
-----------------------------------------------------
Fax | 770-978-0974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 0978
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------