Basic Information
| Provider Information | |||||||||
| NPI: | 1083643761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | J.C. PASSMAN MDPA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 46 SGT PRENTISS DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014429654 | ||||||||
| FaxNumber: | 6014429790 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 SGT PRENTISS DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014429654 | ||||||||
| FaxNumber: | 6014429790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAIMSON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | BRIAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6014429654 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0333 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 204C00000X | 05227 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
No ID Information.