1124051727 NPI number — MR. JED S. MCNALLY PHYSICAL THERAPIST

Table of content: MR. JED S. MCNALLY PHYSICAL THERAPIST (NPI 1124051727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124051727 NPI number — MR. JED S. MCNALLY PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCNALLY
Provider First Name:
JED
Provider Middle Name:
S.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1124051727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2011 HIGHWAY 35 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKPORT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78382-3302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-729-2225
Provider Business Mailing Address Fax Number:
361-729-2483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 CEDAR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78374-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-643-3993
Provider Business Practice Location Address Fax Number:
361-687-2465
Provider Enumeration Date:
07/08/2006

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:  1151595 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8T2904 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1721045-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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