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NPI Code Detail

MEDICARE: GAIL HERNDON FENNIMORE PT

MEDICARE: GAIL HERNDON FENNIMORE PT
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
1225100000XPhysical Therapist1063NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
156-1480824OTHERNCFEDERAL TAX ID
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
364-42619OTHERNCUNITED HEALTHCARE
40103COTHERNCBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1184684920
Entity Type Code : Individual
Provider Name (Legal Business Name) : GAIL HERNDON FENNIMORE PT
Provider Business Mailing Address
First Line : 4012 PARK RD
Second Line : SUITE 200
City : CHARLOTTE
State : NC
Zip : 28209-2377
Country : US
Telephone Number : 704-332-4834
Fax Number : 704-372-9653
Provider Business Practice Location Address
First Line : 4012 PARK RD
Second Line : SUITE 200
City : CHARLOTTE
State : NC
Zip : 28209-2377
Country : US
Telephone Number : 704-332-4834
Fax Number : 704-372-9653
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2006
Last Update Date : 03/07/2013

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Directions to “ GAIL HERNDON FENNIMORE PT” Practice Location

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