Provider Demographics
NPI:1083777882
Name:DESOTO DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:DESOTO DIAGNOSTIC IMAGING, LLC
Other - Org Name:METHODIST DIAGNOSTIC CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-516-1410
Mailing Address - Street 1:9085 SANDIDGE CENTER COVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3575
Mailing Address - Country:US
Mailing Address - Phone:662-536-1000
Mailing Address - Fax:662-893-8824
Practice Address - Street 1:9085 SANDIDGE CENTER COVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3575
Practice Address - Country:US
Practice Address - Phone:662-536-1000
Practice Address - Fax:662-893-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No2471M2300XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMammographyGroup - Multi-Specialty
No2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine TechnologyGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00973276Medicaid
MSC03266Medicare Oscar/Certification