Provider Demographics
NPI:1265800569
Name:WHITESIDE, SARAH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:KIRBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:228-388-5714
Mailing Address - Fax:228-388-0017
Practice Address - Street 1:2541 PASS RD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531
Practice Address - Country:US
Practice Address - Phone:228-388-1002
Practice Address - Fax:228-818-1213
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS529917620Medicaid
MS1003819608OtherGROUP NPI
MS529917620Medicaid