Provider Demographics
NPI:1033271416
Name:GULF STATES PHYSICAL MEDICINE & REHABILITATION
Entity Type:Organization
Organization Name:GULF STATES PHYSICAL MEDICINE & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-944-1717
Mailing Address - Street 1:1190 N STATE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2413
Mailing Address - Country:US
Mailing Address - Phone:601-968-0894
Mailing Address - Fax:601-968-0896
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-968-0894
Practice Address - Fax:601-968-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03077Medicare PIN