Healthcare Provider Details

I. General information

NPI: 1790774263
Provider Name (Legal Business Name): ASSOCIATED RADIOLOGISTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 LANCE ALWORTH DR
BROOKHAVEN MS
39601-2300
US

IV. Provider business mailing address

PO BOX 764
BROOKHAVEN MS
39602-0764
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-6011
  • Fax: 601-835-5413
Mailing address:
  • Phone: 601-833-6011
  • Fax: 601-835-5413

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: MRS. SAUNDRA RENA SHANNON
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-835-5411