Provider Demographics
NPI:1023087855
Name:GOOD SAMARITAN PHYSICAL THERAPY,INC.
Entity type:Organization
Organization Name:GOOD SAMARITAN PHYSICAL THERAPY,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FERMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-638-4076
Mailing Address - Street 1:PO BOX 822394
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39182-2394
Mailing Address - Country:US
Mailing Address - Phone:601-638-4076
Mailing Address - Fax:601-638-4979
Practice Address - Street 1:1901 MISSION 66
Practice Address - Street 2:SUITE A
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-638-4076
Practice Address - Fax:601-638-4979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BN1400X, 332BP3500X, 332BC3200X, 332BX2000X
MS261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000050976OtherBLUE CROSS NUMBER
LA1465739Medicaid
MS09015117Medicaid
MS4253810001OtherDME
MS5429586OtherAETNA PROVIDER NUMBER
MS174112500OtherOWCP
MS6430026OtherUNITED HEALTH CARE NUMBER
MS25-4533Medicare ID - Type UnspecifiedMEDICARE NUMBER
MS6430026OtherUNITED HEALTH CARE NUMBER