Provider Demographics
NPI:1659485241
Name:MEDICAL IMAGING OF GRENADA INC
Entity Type:Organization
Organization Name:MEDICAL IMAGING OF GRENADA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:BARTLETT
Authorized Official - Last Name:BRISTOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-227-7082
Mailing Address - Street 1:PO BOX 16745
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-6745
Mailing Address - Country:US
Mailing Address - Phone:601-227-7082
Mailing Address - Fax:601-227-7088
Practice Address - Street 1:960 AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901
Practice Address - Country:US
Practice Address - Phone:601-227-7082
Practice Address - Fax:601-227-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700322Medicare PIN