Provider Demographics
NPI:1407860315
Name:DIAGNOSTIC RADIOLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:DIAGNOSTIC RADIOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-590-3848
Mailing Address - Street 1:PO BOX 4710
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4710
Mailing Address - Country:US
Mailing Address - Phone:601-936-0494
Mailing Address - Fax:
Practice Address - Street 1:1050 N FLOWOOD DR
Practice Address - Street 2:SUITE A-4
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9738
Practice Address - Country:US
Practice Address - Phone:601-936-0494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011383Medicaid
MSCL2516OtherRR MEDICARE
MS09011383Medicaid