Provider Demographics
NPI:1225164122
Name:GORTON LAB AND X-RAY, LLC
Entity Type:Organization
Organization Name:GORTON LAB AND X-RAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:CARLTON
Authorized Official - Last Name:GORTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-247-2105
Mailing Address - Street 1:PO BOX 633
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-0633
Mailing Address - Country:US
Mailing Address - Phone:662-247-2105
Mailing Address - Fax:662-247-4849
Practice Address - Street 1:107 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BELZONI
Practice Address - State:MS
Practice Address - Zip Code:39038-3929
Practice Address - Country:US
Practice Address - Phone:662-247-2105
Practice Address - Fax:662-247-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty