Basic Information
| Provider Information | |||||||||
| NPI: | 1922165794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAIDLER | ||||||||
| FirstName: | GRAHAM | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6397 LEE HWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4233628684 | ||||||||
| Practice Location | |||||||||
| Address1: | 1106 FOUNTAIN PARK CIR | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315204806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122622151 | ||||||||
| FaxNumber: | 9122622754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 225100000X | PT008385 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 12117846 | 01 | CAQH | OTHER | 375060893B | 05 | GA | MEDICAID | 375060893D | 05 | GA | MEDICAID | 375060893F | 05 | GA | MEDICAID | 375060893E | 05 | GA | MEDICAID |