Provider Demographics
NPI:1568583524
Name:ELECTRODIAGNOSTIC CONSULTANTS, PLLC
Entity Type:Organization
Organization Name:ELECTRODIAGNOSTIC CONSULTANTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:ARTURO
Authorized Official - Last Name:LEIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-981-1234
Mailing Address - Street 1:1350 E WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5112
Mailing Address - Country:US
Mailing Address - Phone:601-981-1234
Mailing Address - Fax:601-981-3989
Practice Address - Street 1:1350 E WOODROW WILSON AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5112
Practice Address - Country:US
Practice Address - Phone:601-981-1234
Practice Address - Fax:601-981-3989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS136672084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015353Medicaid
MSC02553Medicare ID - Type Unspecified