Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | 5969 | SC |
Y | 2251X0800X | Physical Therapist - Orthopedic | 5969 | SC |
NPI | 1295968246 |
---|---|
Provider Name | Philip Lide Gregory |
First Address | Florence, SC 29506-2716 |
Second Address | Florence, SC 29506-2716 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2009 |
Last Update Date | 25/08/2009 |