Healthcare Provider Details

I. General information

NPI: 1558508556
Provider Name (Legal Business Name): PORTABLE MEDICAL DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 01/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DRIVE SUITE G10
JACKSON MS
39216-4926
US

IV. Provider business mailing address

840 US HIGHWAY ONE SUITE 210
NORTH PALM BEACH FL
33408-3833
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-9425
  • Fax: 601-987-0093
Mailing address:
  • Phone: 561-626-9021
  • Fax: 561-626-7593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMRT1971
License Number StateMS

VIII. Authorized Official

Name: DENNIS F ROSEBROUGH
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 561-964-7984