Charles Edward Bouldin, R.P.T.
Individual provider Active NPI Specialist · Tupelo, MS
NPI 1679690101 · NPPES record last updated Nov 8, 2010
Key facts
- NPI
- 1679690101
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Specialist 174400000X
- License
- PT0198 (MS)
- Practice address
- 4749 S Eason Blvd
Suite a
Tupelo, MS 38801-6547 - Phone
- (662) 842-3336
- Fax
- (662) 842-3363
- NPI assigned
- Mar 22, 2007
- Sex
- Male
- Sole proprietor
- Yes
Medicare Care Compare profile
- Specialty
- Physical Therapist in Private Practice
- Education
- Other, 1976
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
Practice addresses (Care Compare)
4749 S Eason Blvd
North Mississippi Physical Therapy
Tupelo, MS 38801-6547
Phone (662) 842-3336
4749 S Eason Blvd a
Tupelo, MS 38801-6547
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20101129000171 | MS | Practitioner - Physical Therapist in Private Practice | 0345436689 | Practice locations: Tupelo, MS |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PT0198 | MS | MD | Specialist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | PT0198 | MS | Yes |
Addresses
Primary practice location
4749 S Eason Blvd
Suite a
Tupelo, MS 38801-6547
Mailing address
4749 S Eason Blvd
Suite a
Tupelo, MS 38801-6547
Phone (662) 842-3336
Other providers in Tupelo, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 8, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.