Provider Demographics
NPI:1598859340
Name:STORM, SAMUEL ERIC (PT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ERIC
Last Name:STORM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:ERIC
Other - Middle Name:
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:290 EAST LAYFAIR DRIVE
Mailing Address - Street 2:STE. B
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9526
Mailing Address - Country:US
Mailing Address - Phone:601-983-1200
Mailing Address - Fax:601-983-1205
Practice Address - Street 1:290 EAST LAYFAIR DRIVE
Practice Address - Street 2:STE. B
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9526
Practice Address - Country:US
Practice Address - Phone:601-983-1200
Practice Address - Fax:601-983-1205
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS426375950OtherBCBS OF MS
MS5116439OtherAETNA PIN