Healthcare Provider Details

I. General information

NPI: 1659482529
Provider Name (Legal Business Name): DIAGNOSTIC TISSUE/CYTOLOGY GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 20TH AVE
MERIDIAN MS
39301-4124
US

IV. Provider business mailing address

PO BOX 3780
TUPELO MS
38803-3780
US

V. Phone/Fax

Practice location:
  • Phone: 601-483-8300
  • Fax: 601-484-7776
Mailing address:
  • Phone: 601-483-8300
  • Fax: 601-484-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number25D1011258
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number25D0980061
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number25D0318506
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number25D0651894
License Number StateMS

VIII. Authorized Official

Name: DR. BRIAN L. WILKINSON
Title or Position: PATHOLOGIST
Credential: M.D.
Phone: 601-553-6809