Basic Information
| Provider Information | |||||||||
| NPI: | 1346332574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICOMP, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDICOMP PHYSICAL THERAPY BYRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 PIONEER WAY | ||||||||
| Address2: | |||||||||
| City: | MAGEE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018496440 | ||||||||
| FaxNumber: | 6013732077 | ||||||||
| Practice Location | |||||||||
| Address1: | 7381 SIWELL RD | ||||||||
| Address2: | STE A | ||||||||
| City: | BYRAM | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392728974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013732075 | ||||||||
| FaxNumber: | 6013732077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | MCNULTY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6018496440 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICOMP, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT2964 | MS | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.