NPIMap

Organization Active NPI

Professional Rehab Associates

  • Physical Therapist
  • McComb, MS
National Provider Identifier
1801192307
Registry record updated Jun 4, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
PROFESSIONAL REHAB ASSOCIATES
Practice address
1301 A Harrison Ave
McComb, MS 39648
Phone
(601) 250-5455
Fax
(601) 250-5453
NPI assigned
Jan 31, 2011
Last updated
Jun 4, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 4, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Brad Wilson, DPT, ATCNPI 1093011595
Title
President
Phone
(601) 250-5455

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physical TherapistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 225100000X Primary
Occupational TherapistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 225X00000X

Addresses

Primary practice location

1301 A Harrison Ave
McComb, MS 39648

Mailing address

1301 A Harrison Ave
McComb, MS 39648
Phone (601) 250-5455

Other practice location 1

631 Brookway Blvd
Brookhaven, MS 39601-2637
Phone (601) 990-2087

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address professionalrehab2@att.net Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110523000605 MS Part B Supplier - Clinic/Group Practice 2567648777 Receives reassigned benefits from 7 practitioners
Practice locations: McComb, MS; Brookhaven, MS
O20120313000177 MS DME Supplier - Independently-Practicing Physical TherapistDME Supplier - Independently-Practicing Occupational Therapist 2567648777 Practice locations: McComb, MS

National Provider Directory

National Provider Directory

Locations

631 Brookway Blvd
Brookhaven, MS 39601
Phone (601) 833-7317

1301 Harrison Ave
#A
McComb, MS 39648
Phone (601) 250-5455

1301A Harrison Ave
McComb, MS 39648
Phone (601) 248-2825

1312 Harrison Ave
Ste B
McComb, MS 39648
Phone (601) 248-2825

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1296432000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1559606400000",
    "number": "1801192307",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1301 A HARRISON AVE",
            "city": "MCCOMB",
            "state": "MS",
            "postal_code": "39648",
            "telephone_number": "601-250-5455",
            "fax_number": "601-250-5453"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1301 A HARRISON AVE",
            "city": "MCCOMB",
            "state": "MS",
            "postal_code": "39648",
            "telephone_number": "601-250-5455",
            "fax_number": "601-250-5453"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "631 Brookway Blvd",
            "address_purpose": "LOCATION",
            "city": "Brookhaven",
            "state": "MS",
            "postal_code": "396012637",
            "country_code": "US",
            "telephone_number": "601-990-2087",
            "fax_number": "601-990-2081",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROFESSIONAL REHAB ASSOCIATES",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-31",
        "last_updated": "2019-06-04",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "BRAD",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "601-250-5455",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "DPT, ATC"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "professionalrehab2@att.net",
            "affiliation": "N",
            "endpointDescription": "email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "631 Brookway Blvd",
            "city": "Brookhaven",
            "state": "MS",
            "country_code": "US",
            "postal_code": "396012637",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in McComb, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 4, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.