Healthcare Provider Details

I. General information

NPI: 1225164122
Provider Name (Legal Business Name): GORTON LAB AND X-RAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CHURCH ST
BELZONI MS
39038-3929
US

IV. Provider business mailing address

PO BOX 633
BELZONI MS
39038-0633
US

V. Phone/Fax

Practice location:
  • Phone: 662-247-2105
  • Fax: 662-247-4849
Mailing address:
  • Phone: 662-247-2105
  • Fax: 662-247-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SIDNEY CARLTON GORTON
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 662-247-2105