Provider Demographics
NPI:1265563423
Name:BERT S. HAYDEL
Entity type:Organization
Organization Name:BERT S. HAYDEL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAYDEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:601-684-0355
Mailing Address - Street 1:300 RAWLS DR
Mailing Address - Street 2:SUITE 700A
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2877
Mailing Address - Country:US
Mailing Address - Phone:601-684-0355
Mailing Address - Fax:601-250-0476
Practice Address - Street 1:300 RAWLS DR
Practice Address - Street 2:SUITE 700A
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2877
Practice Address - Country:US
Practice Address - Phone:601-684-0355
Practice Address - Fax:601-250-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS650816803Medicare PIN