1043987647 NPI number — MS. CAROLINE GORDY FOUNTAIN PHYSICAL THERAPIST

Table of content: MS. CAROLINE GORDY FOUNTAIN PHYSICAL THERAPIST (NPI 1043987647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043987647 NPI number — MS. CAROLINE GORDY FOUNTAIN PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOUNTAIN
Provider First Name:
CAROLINE
Provider Middle Name:
GORDY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GORDY
Provider Other First Name:
CAROLINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043987647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 WEST BEACON STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-650-0002
Provider Business Mailing Address Fax Number:
601-650-9902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13010 HWY 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAYMOND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39154-9526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-857-2229
Provider Business Practice Location Address Fax Number:
601-857-8223
Provider Enumeration Date:
08/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT7134 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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