Provider Demographics
NPI:1114935707
Name:PEARL RIVER REHAB, P.A.
Entity Type:Organization
Organization Name:PEARL RIVER REHAB, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:RAMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-798-8003
Mailing Address - Street 1:1000 FIFTH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3214
Mailing Address - Country:US
Mailing Address - Phone:601-798-8003
Mailing Address - Fax:601-798-6050
Practice Address - Street 1:1000 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3214
Practice Address - Country:US
Practice Address - Phone:601-798-8003
Practice Address - Fax:601-798-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015114Medicaid