Provider Demographics
NPI:1871689851
Name:RIDGELAND SPORTS MEDICINE & REHAB, INC
Entity Type:Organization
Organization Name:RIDGELAND SPORTS MEDICINE & REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:P T
Authorized Official - Phone:601-956-1211
Mailing Address - Street 1:665 S PEAR ORCHARD RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4861
Mailing Address - Country:US
Mailing Address - Phone:601-956-1211
Mailing Address - Fax:601-956-2282
Practice Address - Street 1:665 S PEAR ORCHARD RD
Practice Address - Street 2:SUITE 114
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4861
Practice Address - Country:US
Practice Address - Phone:601-956-1211
Practice Address - Fax:601-956-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS PT0747261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5965404OtherAETNA