1366564999 NPI number — MRS. TERRILYN ETHERIDGE PHYSICAL THERAPIST

Table of content: MRS. TERRILYN ETHERIDGE PHYSICAL THERAPIST (NPI 1366564999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366564999 NPI number — MRS. TERRILYN ETHERIDGE PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETHERIDGE
Provider First Name:
TERRILYN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ETHERIDGE
Provider Other First Name:
TERRILYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICAL THERAPIST
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366564999
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 TROUVILLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23505-2944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-478-6006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5900 CHURCHLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23703-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-483-0333
Provider Business Practice Location Address Fax Number:
757-483-9359
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2305005821 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 191880 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 371787 . This is a "MDIPA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 62413 . This is a "MAILHANDLERS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 808578 . This is a "MPN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 26207 . This is a "OPTIMA MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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