Basic Information
Provider Information
NPI: 1316297500
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DILL
FirstName: STEPHEN
MiddleName: DWIGHT
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 965 RIDGE LAKE BLVD STE 103
Address2:  
City: MEMPHIS
State: TN
PostalCode: 381209446
CountryCode: US
TelephoneNumber: 9012273255
FaxNumber: 9012278591
Practice Location
Address1: 1200 N STATE ST STE 210
Address2:  
City: JACKSON
State: MS
PostalCode: 392022000
CountryCode: US
TelephoneNumber: 6017143202
FaxNumber: 6017143416
Other Information
ProviderEnumerationDate: 09/14/2012
LastUpdateDate: 02/03/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/03/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT5171MSY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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