=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619416088
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN MARK DICKERMAN DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2017
-----------------------------------------------------
Last Update Date | 12/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 810 VALLEY RD
-----------------------------------------------------
City | MOCKSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27028-2930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-753-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 CORPORATE DR STE 400
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-238-7217
-----------------------------------------------------
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 | P16899
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------