Provider Demographics
NPI:1184685448
Name:GRENADA DIAGNOSTIC RADIOLOGY
Entity Type:Organization
Organization Name:GRENADA DIAGNOSTIC RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-226-9279
Mailing Address - Street 1:1300 SUNSET DR
Mailing Address - Street 2:SUITE U
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4086
Mailing Address - Country:US
Mailing Address - Phone:662-226-9279
Mailing Address - Fax:662-226-9779
Practice Address - Street 1:1300 SUNSET DR
Practice Address - Street 2:SUITE U
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-226-9279
Practice Address - Fax:662-226-9779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS222008261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125988Medicaid
MS47000034Medicare ID - Type UnspecifiedMEDICARE PROVIDER