Provider Demographics
NPI:1154414167
Name:WHITE, ETHAN (MSPT)
Entity type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 INDEPENDENCE DRIVE
Mailing Address - Street 2:300B
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209
Mailing Address - Country:US
Mailing Address - Phone:205-879-7501
Mailing Address - Fax:205-879-0675
Practice Address - Street 1:3125 INDEPENDENCE DRIVE
Practice Address - Street 2:300B
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209
Practice Address - Country:US
Practice Address - Phone:205-879-7501
Practice Address - Fax:205-879-0675
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH2033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6400002OtherUNITED HEALTH CARE
AL51094044OtherBLUE CROSS
AL418961932OtherTRICARE
AL000094044Medicare ID - Type Unspecified
P90876Medicare UPIN