=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871022103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILDERMAN PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2626 BELAIRE DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-3835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-691-9055
-----------------------------------------------------
Fax | 302-444-8440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2626 BELAIRE DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-3835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-691-9055
-----------------------------------------------------
Fax | 302-444-8440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. DAVID WILDERMAN
-----------------------------------------------------
Credential | PT, DPT, MS
-----------------------------------------------------
Telephone | 302-691-9055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-006145L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | DAPT002107
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | J1-0002854
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------