Provider Demographics
NPI:1235151135
Name:LANDRUM, SAMUEL ERNEST (PT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ERNEST
Last Name:LANDRUM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 S CURRAN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-4524
Mailing Address - Country:US
Mailing Address - Phone:601-749-8145
Mailing Address - Fax:601-749-8146
Practice Address - Street 1:220 S CURRAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-4524
Practice Address - Country:US
Practice Address - Phone:601-749-8145
Practice Address - Fax:601-749-8146
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist