Basic Information
| Provider Information | |||||||||
| NPI: | 1265977847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID SOUTH REHAB OUTPATIENT CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | 360 REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 6016071415 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 6016071415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2017 | ||||||||
| LastUpdateDate: | 08/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | MCGEE | ||||||||
| AuthorizedOfficialFirstName: | ANNELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
| AuthorizedOfficialTelephone: | 6016056777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.