Healthcare Provider Details

I. General information

NPI: 1962682468
Provider Name (Legal Business Name): MERIDIAN IMAGING, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 CONSTITUTION AVE FIRST FLOOR
MERIDIAN MS
39301-4001
US

IV. Provider business mailing address

PO BOX 5653
MERIDIAN MS
39302-5653
US

V. Phone/Fax

Practice location:
  • Phone: 601-693-5843
  • Fax: 601-693-0173
Mailing address:
  • Phone: 601-693-5843
  • Fax: 601-693-0173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL STACY THAGGARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-693-5843