=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609877356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMB RADIOLOGY P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2005
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 MARKET ST
-----------------------------------------------------
City | PASCAGOULA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39567-6604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-762-1353
-----------------------------------------------------
Fax | 228-762-1359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 749627
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-9627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-264-3435
-----------------------------------------------------
Fax | 706-596-6704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CLIFTON T LEATHERBURY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 228-762-1353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------