Basic Information
| Provider Information | |||||||||
| NPI: | 1447359229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUMGARDNER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 322 BAKER ST | ||||||||
| Address2: | |||||||||
| City: | PETAL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394653806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014673442 | ||||||||
| FaxNumber: | 2563507757 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 HIGHWAY 42 | ||||||||
| Address2: | |||||||||
| City: | PETAL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394659740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015440500 | ||||||||
| FaxNumber: | 6015440505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | PT3992 | MS | Y | Other Service Providers | Specialist |
No ID Information.