Basic Information
| Provider Information | |||||||||
| NPI: | 1730779224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SU | ||||||||
| FirstName: | FAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | SU | ||||||||
| OtherFirstName: | MAGGIE | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1851 S LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HILLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352161623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263216609 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7054 VETERANS PKWY | ||||||||
| Address2: | |||||||||
| City: | PELL CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351255117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052277985 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2021 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH9502 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.