Provider Demographics
NPI:1881822708
Name:MISSISSIPPI DIVERSIFIED HEALTHCARE INC
Entity Type:Organization
Organization Name:MISSISSIPPI DIVERSIFIED HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-442-3968
Mailing Address - Street 1:PO BOX 18394
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39122-8394
Mailing Address - Country:US
Mailing Address - Phone:601-442-1285
Mailing Address - Fax:601-446-9683
Practice Address - Street 1:133 JEFFERSON DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5103
Practice Address - Country:US
Practice Address - Phone:770-443-4483
Practice Address - Fax:770-443-4410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS183482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty