Healthcare Provider Details

I. General information

NPI: 1861428351
Provider Name (Legal Business Name): LAKELAND RADIOLOGISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

PO BOX 23073
JACKSON MS
39225-3073
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-7878
  • Fax: 706-596-6704
Mailing address:
  • Phone: 601-982-7878
  • Fax: 705-596-6704

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: MR. GEORGE EHRHARDT
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-982-7878