Basic Information
| Provider Information | |||||||||
| NPI: | 1114229168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICOMP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1392 W GOVERNMENT ST # C | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390423049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018248814 | ||||||||
| FaxNumber: | 6018248816 | ||||||||
| Practice Location | |||||||||
| Address1: | 1392 W GOVERNMENT ST # C | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390423049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018248814 | ||||||||
| FaxNumber: | 6018248816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2010 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCNULTY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6018496440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 07923828 | 05 | MS | MEDICAID |