MEDICARE: MR. JAMES E NETTLES RPT

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	PTH4152	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51528524	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1417923137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES E NETTLES RPT

Provider Business Mailing Address
First Line	:	6767 OLD MADISON PIKE
Second Line	:	SUITE 400
City	:	HUNTSVILLE
State	:	AL
Zip	:	35806-2172
Country	:	US
Telephone Number	:	256-922-6650
Fax Number	:	256-922-6651

Provider Business Practice Location Address
First Line	:	6767 OLD MADISON PIKE
Second Line	:	SUITE 400
City	:	HUNTSVILLE
State	:	AL
Zip	:	35806-2172
Country	:	US
Telephone Number	:	256-922-6650
Fax Number	:	256-922-6651

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	07/08/2007

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