Provider Demographics
NPI:1043260763
Name:MID-SOUTH IMAGING & THERAPEUTICS, P.A.
Entity Type:Organization
Organization Name:MID-SOUTH IMAGING & THERAPEUTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELLZEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-473-6406
Mailing Address - Street 1:PO BOX 5083
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-5083
Mailing Address - Country:US
Mailing Address - Phone:901-383-8860
Mailing Address - Fax:901-383-8985
Practice Address - Street 1:7600 WOLF RIVER BLVD.
Practice Address - Street 2:#200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-747-1000
Practice Address - Fax:901-747-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0022687OtherGROUP TN BCBS #
MS09013816Medicaid
AR107365002Medicaid
TN3373325Medicaid
MO508212206Medicaid
AR86018OtherGROUP AR BCBS #
MSC02273Medicare ID - Type UnspecifiedGROUP MS M'CARE #
AR107365002Medicaid
TN3373325Medicaid