Basic Information
| Provider Information | |||||||||
| NPI: | 1033271416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF STATES PHYSICAL MEDICINE & REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1190 N STATE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019680894 | ||||||||
| FaxNumber: | 6019680896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 N STATE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019680894 | ||||||||
| FaxNumber: | 6019680896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 01/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRISSETT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6019441717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.