Provider Demographics
NPI:1508967928
Name:TRUSSELL, GREGORY H (PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:H
Last Name:TRUSSELL
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 1:201 HIGHWAY 51 # A
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4425
Mailing Address - Country:US
Mailing Address - Phone:601-898-4324
Mailing Address - Fax:601-898-4325
Practice Address - Street 1:201 HIGHWAY 51 # A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4425
Practice Address - Country:US
Practice Address - Phone:601-898-4324
Practice Address - Fax:601-898-4325
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS256527Medicare ID - Type Unspecified