Healthcare Provider Details

I. General information

NPI: 1669542353
Provider Name (Legal Business Name): GOOD SAMARITAN PEDIATRICS SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 LAKELAND DR SUITE B
FLOWOOD MS
39232-9571
US

IV. Provider business mailing address

PO BOX 822394
VICKSBURG MS
39182-2394
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-4076
  • Fax: 601-638-4979
Mailing address:
  • Phone: 601-638-4076
  • Fax: 601-638-4979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: FERMIKA SMITH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 601-638-4076