MEDICARE: MR. GARY R CADDELL MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PTH2675	AL

General Provider Information

NPI Number	:	1114157617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARY R CADDELL MSPT

Provider Business Mailing Address
First Line	:	245 CAHABA VALLEY ROAD
Second Line	:	SUITE 200
City	:	PELHAM
State	:	AL
Zip	:	35124-2217
Country	:	US
Telephone Number	:	205-942-6820
Fax Number	:

Provider Business Practice Location Address
First Line	:	3141 OLD COLUMBIANA RD
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35226-3703
Country	:	US
Telephone Number	:	205-822-1580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2009
Last Update Date	:	07/17/2009

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