=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538793237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ALLISON CARGILL PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2020
-----------------------------------------------------
Last Update Date | 03/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 N BREVARD ST APT 217
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28206-3615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-360-9093
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 BLYTHE BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28203-5814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-355-7760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | P19392
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------