Provider Demographics
NPI:1447318159
Name:BOSARGE, ADA RUTH (PT CMDT)
Entity type:Individual
Prefix:MRS
First Name:ADA
Middle Name:RUTH
Last Name:BOSARGE
Suffix:
Gender:F
Credentials:PT CMDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567
Mailing Address - Country:US
Mailing Address - Phone:228-762-2345
Mailing Address - Fax:228-762-2365
Practice Address - Street 1:2838 ANDREW ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567
Practice Address - Country:US
Practice Address - Phone:228-762-2345
Practice Address - Fax:228-762-2365
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016039Medicaid
MS00124841Medicaid
MS09016039Medicaid