Provider Demographics
NPI:1184652737
Name:SPORTS MEDICINE LTD
Entity Type:Organization
Organization Name:SPORTS MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:228-255-6868
Mailing Address - Street 1:17000 KAPALAMA RD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571
Mailing Address - Country:US
Mailing Address - Phone:228-255-6868
Mailing Address - Fax:228-255-6860
Practice Address - Street 1:17000 KAPALAMA RD.
Practice Address - Street 2:SUITE B.
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571
Practice Address - Country:US
Practice Address - Phone:228-255-6868
Practice Address - Fax:228-255-6860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2013-02-18
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
MS07508214Medicaid
MS07508214Medicaid
MS07508214Medicaid