Provider Demographics
NPI:1417907536
Name:IMAGING CENTER AT GLOSTER CREEK VILLAGE PLLC
Entity Type:Organization
Organization Name:IMAGING CENTER AT GLOSTER CREEK VILLAGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHAEFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-300-0101
Mailing Address - Street 1:320 S GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4748
Mailing Address - Country:US
Mailing Address - Phone:662-841-7880
Mailing Address - Fax:662-821-1888
Practice Address - Street 1:320 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4748
Practice Address - Country:US
Practice Address - Phone:662-841-7880
Practice Address - Fax:662-821-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
123156800OtherDEPT OF LABOR #
MS09016308Medicaid
DA0120OtherMEDICARE RAILROAD
MS09016308Medicaid