Provider Demographics
NPI:1922291301
Name:MADDOX, RENEE A (RPT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:MADDOX
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:TRINITY REHAB
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158
Mailing Address - Country:US
Mailing Address - Phone:601-206-9195
Mailing Address - Fax:601-957-8391
Practice Address - Street 1:13 NORTHTOWN DR
Practice Address - Street 2:SUITE 110 TRINITY REHAB
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-206-9195
Practice Address - Fax:601-957-8391
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014160Medicaid
MS256542Medicare PIN