Basic Information
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| NPI: | 1790774263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED RADIOLOGISTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 764 | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396020764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018336011 | ||||||||
| FaxNumber: | 6018355413 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 LANCE ALWORTH DR | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018336011 | ||||||||
| FaxNumber: | 6018355413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHANNON | ||||||||
| AuthorizedOfficialFirstName: | SAUNDRA | ||||||||
| AuthorizedOfficialMiddleName: | RENA | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6018355411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 09011113 | 05 | MS | MEDICAID |