Healthcare Provider Details

I. General information

NPI: 1174804355
Provider Name (Legal Business Name): PORTABLE MEDICAL DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DR STE G10
JACKSON MS
39216-4926
US

IV. Provider business mailing address

1855 LAKELAND DR STE G10
JACKSON MS
39216-4926
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-9729
  • Fax: 601-987-0093
Mailing address:
  • Phone: 601-987-9729
  • Fax: 601-987-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: DOUGLAS BROWN
Title or Position: MANAGING PARTNER
Credential:
Phone: 601-260-6008