MEDICARE: MOBILE HEART STATION INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number
1	246XS1301X	Sonography Specialist/Technologist Cardiovascular	ARDMS11532
2	2471S1302X	Sonography Radiologic Technologist	ARDMS
3	246XC2903X	Vascular Specialist/Technologist Cardiovascular	ARDMS11532

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	470000422	OTHER	MS	MEDICARE RAILROAD
3	5CB82	OTHER	LA	MEDICARE OF LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356428569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE HEART STATION INC

Provider Business Mailing Address
First Line	:	196 TIMBERLANE ROAD
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466
Country	:	US
Telephone Number	:	601-799-5169
Fax Number	:	601-799-3998

Provider Business Practice Location Address
First Line	:	196 TIMBERLANE ROAD
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466
Country	:	US
Telephone Number	:	601-799-5169
Fax Number	:	601-799-3998

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	DR. WAR T VICHAYANOND
Credential	:	PHD FASE RDCS
Telephone Number	:	601-799-5169

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	11/02/2010

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Directions to “MOBILE HEART STATION INC ” Practice Location

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