Provider Demographics
NPI:1396839908
Name:SHORT, DENNIS RYAN (PT)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RYAN
Last Name:SHORT
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 1:810 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732
Mailing Address - Country:US
Mailing Address - Phone:662-843-4990
Mailing Address - Fax:662-843-4954
Practice Address - Street 1:810 E SUNFLOWER RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-843-4990
Practice Address - Fax:662-843-4954
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03258055Medicaid
MS03258055Medicaid
MS650000205Medicare ID - Type Unspecified