Provider Demographics
NPI:1306877501
Name:SCHMIDT, MARK (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 KAPALAMA RD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:PASS CHRISTIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39571
Mailing Address - Country:US
Mailing Address - Phone:228-255-6868
Mailing Address - Fax:228-255-6860
Practice Address - Street 1:17000 KAPALAMA RD.
Practice Address - Street 2:SUITE
Practice Address - City:PASS CHRISTIAN
Practice Address - State:MS
Practice Address - Zip Code:39571
Practice Address - Country:US
Practice Address - Phone:228-255-6868
Practice Address - Fax:228-255-6860
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120984Medicaid
MS650000291Medicare ID - Type Unspecified