Healthcare Provider Details

I. General information

NPI: 1447359229
Provider Name (Legal Business Name): JOHN PAUL BUMGARDNER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 HIGHWAY 42
PETAL MS
39465-9740
US

IV. Provider business mailing address

322 BAKER ST
PETAL MS
39465-3806
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-0500
  • Fax: 601-544-0505
Mailing address:
  • Phone: 601-467-3442
  • Fax: 256-350-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT3992
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: