Healthcare Provider Details

I. General information

NPI: 1275450454
Provider Name (Legal Business Name): AUSTIN TAYLOR GOODMAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1976 HIGHWAY 43 N
CANTON MS
39046-4962
US

IV. Provider business mailing address

25025 HIGHWAY 15
UNION MS
39365-8577
US

V. Phone/Fax

Practice location:
  • Phone: 601-667-3144
  • Fax: 601-667-3730
Mailing address:
  • Phone: 769-222-1053
  • Fax: 769-222-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT8188
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: