Basic Information
| Provider Information | |||||||||
| NPI: | 1386931673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADDISON | ||||||||
| FirstName: | ROBBIE | ||||||||
| MiddleName: | BRANDON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | D.P.T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 JOHNSTON ST SE STE 200 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563501764 | ||||||||
| FaxNumber: | 3343964905 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EUFAULA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360271847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346887155 | ||||||||
| FaxNumber: | 3346167615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 915 | AL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PTH6169 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 511-60916 | 01 | AL | BCBS OF AL | OTHER | 12735267 | 01 | AL | CAQH | OTHER | 511-19134 | 01 | AL | BCBS OF AL | OTHER |