MEDICARE: DEREK L WHITEHEAD PT, ATC

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	05008312A	IN

General Provider Information

NPI Number	:	1942059779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK L WHITEHEAD PT, ATC

Provider Business Mailing Address
First Line	:	6059 CHINKAPIN DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-8448
Country	:	US
Telephone Number	:	812-447-9891
Fax Number	:

Provider Business Practice Location Address
First Line	:	6059 CHINKAPIN DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-8448
Country	:	US
Telephone Number	:	812-447-9891
Fax Number	:

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

Provider Enumeration Date	:	05/14/2024
Last Update Date	:	05/14/2024

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