Provider Demographics
NPI:1952614414
Name:MEDICOMP PHYSICAL THERAPY RIDGELAND, INC.
Entity Type:Organization
Organization Name:MEDICOMP PHYSICAL THERAPY RIDGELAND, INC.
Other - Org Name:MEDICOMP PHYSICAL THERAPY RIDGELAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-1682
Mailing Address - Street 1:665 S PEAR ORCHARD RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4861
Mailing Address - Country:US
Mailing Address - Phone:601-956-1211
Mailing Address - Fax:
Practice Address - Street 1:665 S PEAR ORCHARD RD
Practice Address - Street 2:SUITE 114
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4861
Practice Address - Country:US
Practice Address - Phone:601-956-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty