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1861699639 NPI number — BRET SHERIDAN DERRICK PT, DPT, OCS

NPI Number: 1861699639
Health Care Provider/Practitioner: BRET SHERIDAN DERRICK PT, DPT, OCS

Information about “1861699639” NPI (BRET SHERIDAN DERRICK PT, DPT, OCS) exists in 1861699639 in HTML format HTML  |  1861699639 in plain Text format TXT  |  1861699639 in PDF (Portable Document Format) PDF  |  1861699639 in an XML format XML  formats.

NPI Number : 1861699639 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1861699639",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "DERRICK",
    "FirstName": "BRET",
    "MiddleName": "SHERIDAN",
    "NamePrefix": "MR.",
    "NameSuffix": null,
    "Credential": "PT, DPT, OCS",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "111 E BROADWAY STE 340",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "COLUMBIA",
    "MailingAddressStateName": "MO",
    "MailingAddressPostalCode": "65203-4208",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "573-808-2392",
    "MailingAddressFaxNumber": "888-738-3034",
    "FirstLinePracticeLocationAddress": "111 E BROADWAY STE 340",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "COLUMBIA",
    "PracticeLocationAddressStateName": "MO",
    "PracticeLocationAddressPostalCode": "65203-4208",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "573-808-2392",
    "PracticeLocationAddressFaxNumber": "888-738-3034",
    "EnumerationDate": "06/27/2007",
    "LastUpdateDate": "04/23/2018",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "2251E1200X",
          "TaxonomyName": "Ergonomics Physical Therapist",
          "LicenseNumber": "01248",
          "LicenseNumberStateCode": "MO",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "2251X0800X",
          "TaxonomyName": "Orthopedic Physical Therapist",
          "LicenseNumber": "01248",
          "LicenseNumberStateCode": "MO",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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