=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669419784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL DIAGNOSTIC SERVICE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 08/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 N. WARD BLVD. SUITE A
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-237-0848
-----------------------------------------------------
Fax | 252-237-0848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 63
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-237-0848
-----------------------------------------------------
Fax | 252-237-0848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK HOOPER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 252-237-0848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2471S1302X
-----------------------------------------------------
Taxonomy Name | Sonography Radiologic Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246ZE0600X
-----------------------------------------------------
Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------