Provider Demographics
NPI:1407008972
Name:SOUTHERN MEDICAL IMAGING
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENDUSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-579-4500
Mailing Address - Street 1:1 LINCOLN PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 LINCOLN PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3262
Practice Address - Country:US
Practice Address - Phone:601-579-4463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09008521Medicaid
470000041Medicare PIN