Provider Demographics
NPI:1114001328
Name:BAZEMORE, CURTIS WRIGHT (PT, ATC)
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:WRIGHT
Last Name:BAZEMORE
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RIVERSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5925
Mailing Address - Country:US
Mailing Address - Phone:770-237-3475
Mailing Address - Fax:770-237-3756
Practice Address - Street 1:1900 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5925
Practice Address - Country:US
Practice Address - Phone:770-237-3475
Practice Address - Fax:770-237-3756
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT000825225100000X
GAATC0002382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00416901OtherRAILROAD MEDICARE
GAQ53436Medicare UPIN
GA65BBDFTMedicare PIN