Provider Demographics
NPI:1154430213
Name:FITZGERALD, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 WHITEWELD TER
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-5205
Mailing Address - Country:US
Mailing Address - Phone:910-313-0730
Mailing Address - Fax:
Practice Address - Street 1:2001 S 17TH ST
Practice Address - Street 2:STE 101
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6628
Practice Address - Country:US
Practice Address - Phone:970-763-8184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8519OtherLICENSE #