Provider Demographics
NPI:1790774263
Name:ASSOCIATED RADIOLOGISTS PA
Entity Type:Organization
Organization Name:ASSOCIATED RADIOLOGISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAUNDRA
Authorized Official - Middle Name:RENA
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-835-5411
Mailing Address - Street 1:PO BOX 764
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39602-0764
Mailing Address - Country:US
Mailing Address - Phone:601-833-6011
Mailing Address - Fax:601-835-5413
Practice Address - Street 1:108 LANCE ALWORTH DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2300
Practice Address - Country:US
Practice Address - Phone:601-833-6011
Practice Address - Fax:601-835-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011113Medicaid
MS09011113Medicaid