=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861699639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRET SHERIDAN DERRICK PT, DPT, OCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 04/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 E BROADWAY STE 340
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-808-2392
-----------------------------------------------------
Fax | 888-738-3034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 E BROADWAY STE 340
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65203-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-808-2392
-----------------------------------------------------
Fax | 888-738-3034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251E1200X
-----------------------------------------------------
Taxonomy Name | Ergonomics Physical Therapist
-----------------------------------------------------
License Number | 01248
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 01248
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------