Provider Demographics
NPI:1487856084
Name:SLEEP CONSULTANTS DIAGNOSTIC LAB
Entity Type:Organization
Organization Name:SLEEP CONSULTANTS DIAGNOSTIC LAB
Other - Org Name:SLEEP CONSULTANTS SLEEP CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-982-7111
Mailing Address - Street 1:403 TOWNE CENTER BLVD
Mailing Address - Street 2:STE 101A
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4843
Mailing Address - Country:US
Mailing Address - Phone:601-982-7111
Mailing Address - Fax:601-981-2524
Practice Address - Street 1:403 TOWNE CENTER BLVD
Practice Address - Street 2:STE 101A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4843
Practice Address - Country:US
Practice Address - Phone:601-982-7111
Practice Address - Fax:601-981-2524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08416207RS0012X, 261QS1200X
261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302G708148OtherMEDICARE PTAN
MS00010055Medicaid
MSC48044Medicare UPIN
MS1487856084Medicare NSC
MS00010055Medicaid