Healthcare Provider Details

I. General information

NPI: 1013217074
Provider Name (Legal Business Name): SHARKEY ISSAQUENA COMM HOSPITAL - RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 S FOURTH ST
ROLLING FORK MS
39159-5146
US

IV. Provider business mailing address

47 S FOURTH ST
ROLLING FORK MS
39159-5146
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-5171
  • Fax: 662-873-5194
Mailing address:
  • Phone: 662-873-5171
  • Fax: 662-873-5194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY LORETO
Title or Position: DIRECTOR HIS / BUSINESS OFFICE
Credential:
Phone: 662-873-5171