=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689620510
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON C RIDDLE PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 02/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4543 MCKNIGHT RD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15237-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-748-1616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1204 E ELFINWILD RD
-----------------------------------------------------
City | ALLISON PARK
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15101-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-213-0881
-----------------------------------------------------
Fax | 412-231-0881
-----------------------------------------------------
=====================================================
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 | PT017595
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------