Provider Demographics
NPI:1346317344
Name:SPECIALIZED PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SPECIALIZED PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPTA
Authorized Official - Phone:601-420-0717
Mailing Address - Street 1:533B KEYWAY DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8809
Mailing Address - Country:US
Mailing Address - Phone:601-420-0717
Mailing Address - Fax:601-420-0957
Practice Address - Street 1:533B KEYWAY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8809
Practice Address - Country:US
Practice Address - Phone:601-420-0717
Practice Address - Fax:601-420-0957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP20612Medicare UPIN
MSC03130Medicare PIN