Healthcare Provider Details

I. General information

NPI: 1518284181
Provider Name (Legal Business Name): PORTABLE MEDICAL DIAGNOSTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2010
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DR SUITE G10
JACKSON MS
39216-4913
US

IV. Provider business mailing address

1855 LAKELAND DR SUITE G10
JACKSON MS
39216-4913
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-9425
  • 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 Number4975007
License Number StateMS

VIII. Authorized Official

Name: DOUGLAS BROWN
Title or Position: MANAGING MEMBER
Credential:
Phone: 601-987-9729