Provider Demographics
NPI:1518284181
Name:PORTABLE MEDICAL DIAGNOSTICS INC
Entity Type:Organization
Organization Name:PORTABLE MEDICAL DIAGNOSTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-987-9729
Mailing Address - Street 1:1855 LAKELAND DR
Mailing Address - Street 2:SUITE G10
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4913
Mailing Address - Country:US
Mailing Address - Phone:601-987-9729
Mailing Address - Fax:601-987-0093
Practice Address - Street 1:1855 LAKELAND DR
Practice Address - Street 2:SUITE G10
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4913
Practice Address - Country:US
Practice Address - Phone:601-987-9425
Practice Address - Fax:601-987-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4975007261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302G477312Medicare PIN