Provider Demographics
NPI:1346332574
Name:MEDICOMP, INC
Entity Type:Organization
Organization Name:MEDICOMP, INC
Other - Org Name:MEDICOMP PHYSICAL THERAPY BYRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:110 PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-373-2077
Practice Address - Street 1:7381 SIWELL RD
Practice Address - Street 2:STE A
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-8974
Practice Address - Country:US
Practice Address - Phone:601-373-2075
Practice Address - Fax:601-373-2077
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICOMP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-28
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MSPT2964261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS650000284Medicare ID - Type Unspecified