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General NPI Number Information
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NPI Number | 1487904173
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Entity Type | Organization
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Legal Business Name | MID DELTA RADIOLOGY ASSOCIATES, LLC
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Dates
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Enumeration Date | 09/11/2012
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Last Update Date | 07/05/2023
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Provider Practice Location Address
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Address Line | 130 RIVER CLUB CIR
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City | CLARKSDALE
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State | MS
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Zip | 38614-9725
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Country | US
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Telephone | 662-832-3514
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Fax | 866-782-0773
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Provider Business Mailing Address
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Address Line | 130 RIVER CLUB CIR
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City | CLARKSDALE
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State | MS
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Zip | 38614-9725
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Country | US
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Telephone | 662-832-3514
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Fax | 866-782-0773
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Authorized Official
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Title or Position | MANAGER
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Name | KELLEY OLIVER
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Credential |
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Telephone | 662-832-3514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | E7789
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License Number State | AR
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