Provider Demographics
NPI:1407158454
Name:MEDICOMP, INC
Entity Type:Organization
Organization Name:MEDICOMP, INC
Other - Org Name:DOGWOOD PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:151 E METRO DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-4402
Mailing Address - Country:US
Mailing Address - Phone:601-664-7191
Mailing Address - Fax:601-664-7149
Practice Address - Street 1:151 E METRO DR
Practice Address - Street 2:SUITE 106
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-4402
Practice Address - Country:US
Practice Address - Phone:601-664-7191
Practice Address - Fax:601-664-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
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
MS09635221Medicaid