Provider Demographics
NPI:1134141245
Name:MID SOUTH RADIOLOGY PARTNERS, LLC
Entity Type:Organization
Organization Name:MID SOUTH RADIOLOGY PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-546-6643
Mailing Address - Street 1:107 E SHANKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-4709
Mailing Address - Country:US
Mailing Address - Phone:866-546-6643
Mailing Address - Fax:337-824-4199
Practice Address - Street 1:107 E SHANKLAND AVE
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4709
Practice Address - Country:US
Practice Address - Phone:337-824-4525
Practice Address - Fax:337-824-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1446726Medicaid
LA1446726Medicaid