Basic Information
| Provider Information | |||||||||
| NPI: | 1982091450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUEITT | ||||||||
| FirstName: | PHILLIP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 JOHNSTON ST SE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356012515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563409708 | ||||||||
| FaxNumber: | 2563409624 | ||||||||
| Practice Location | |||||||||
| Address1: | 5643 SERMON RD S | ||||||||
| Address2: | |||||||||
| City: | THEODORE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365823608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516601505 | ||||||||
| FaxNumber: | 2516609007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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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 | PTH5760 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 529917620 | 05 | AL | MEDICAID | 1003819608 | 01 | AL | GROUP NPI | OTHER |