Healthcare Provider Details

I. General information

NPI: 1205991072
Provider Name (Legal Business Name): MISSOURI DELTA RADIOLOGY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

PO BOX 781
SIKESTON MO
63801-0781
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-7342
  • Fax: 573-472-3242
Mailing address:
  • Phone: 314-821-8055
  • Fax: 314-821-1833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MAHMOUD ZIAEE
Title or Position: PRESIDENT
Credential: MD
Phone: 573-472-7342