Provider Demographics
NPI:1932489812
Name:PORTABLE MEDICAL DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:PORTABLE MEDICAL DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
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:601-260-6008
Mailing Address - Street 1:1855 LAKELAND DR
Mailing Address - Street 2:STE 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:STE G10
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4913
Practice Address - Country:US
Practice Address - Phone:601-987-9729
Practice Address - Fax:601-987-0093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302G639824Medicare PIN