Provider Demographics
NPI:1669542353
Name:GOOD SAMARITAN PEDIATRICS SPECIALISTS
Entity type:Organization
Organization Name:GOOD SAMARITAN PEDIATRICS SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
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 1:4290 LAKELAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9571
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:2006-11-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03675793Medicaid