Healthcare Provider Details

I. General information

NPI: 1174775589
Provider Name (Legal Business Name): GEORGE REGIONAL RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 RATLIFF ST
LUCEDALE MS
39452-6537
US

IV. Provider business mailing address

PO BOX 628
LUCEDALE MS
39452
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8181
  • Fax:
Mailing address:
  • Phone: 601-947-8181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19622
License Number StateMS

VIII. Authorized Official

Name: MS. KATHY FENDER
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-947-8181