Basic Information
| Provider Information | |||||||||
| NPI: | 1053786996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAPTIST PT- LYMPHEDEMA CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019746243 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019746243 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2015 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRISSETT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6019441717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.