Healthcare Provider Details

I. General information

NPI: 1407860315
Provider Name (Legal Business Name): DIAGNOSTIC RADIOLOGY ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 N FLOWOOD DR SUITE A-4
FLOWOOD MS
39232-9738
US

IV. Provider business mailing address

PO BOX 4710
JACKSON MS
39296-4710
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-0494
  • Fax:
Mailing address:
  • Phone: 601-936-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. JEFFREY SCOTT FORTSON
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 770-590-3848