Healthcare Provider Details

I. General information

NPI: 1568558385
Provider Name (Legal Business Name): CENTRAL MS IMAGING LLC DBA SOUTHERN DIAGNOSTIC IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 N FLOWOOD DR
FLOWOOD MS
39232-9533
US

IV. Provider business mailing address

1037 N FLOWOOD DR
FLOWOOD MS
39232-9533
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-0302
  • Fax:
Mailing address:
  • Phone: 601-936-0302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE STUART
Title or Position: CREDENTIALING REPRESENTATIVE 2
Credential:
Phone: 601-200-4880