Basic Information
| Provider Information | |||||||||
| NPI: | 1679817928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PT, DPT, CMTPT, FMSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Practice Location | |||||||||
| Address1: | 3510 ANDERSON HWY STE 2 | ||||||||
| Address2: | |||||||||
| City: | POWHATAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 231395846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045982100 | ||||||||
| FaxNumber: | 8045987624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2012 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305207682 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01462267 | 01 | VA | MEDICARE RR PTAN | OTHER | C05954 | 01 | VA | GROUP MEDICARE PTAN | OTHER | 1679817928 | 05 | VA | MEDICAID |