Healthcare Provider Details

I. General information

NPI: 1023087855
Provider Name (Legal Business Name): GOOD SAMARITAN PHYSICAL THERAPY,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MISSION 66 SUITE A
VICKSBURG MS
39180-3711
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 TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateMS

VIII. Authorized Official

Name: MRS. FERMIKA SMITH
Title or Position: BILLING MANAGER
Credential:
Phone: 601-638-4076