Provider Demographics
NPI:1356428569
Name:MOBILE HEART STATION INC
Entity type:Organization
Organization Name:MOBILE HEART STATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WAR
Authorized Official - Middle Name:T
Authorized Official - Last Name:VICHAYANOND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD FASE RDCS
Authorized Official - Phone:601-799-5169
Mailing Address - Street 1:196 TIMBERLANE ROAD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466
Mailing Address - Country:US
Mailing Address - Phone:601-799-5169
Mailing Address - Fax:601-799-3998
Practice Address - Street 1:196 TIMBERLANE ROAD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466
Practice Address - Country:US
Practice Address - Phone:601-799-5169
Practice Address - Fax:601-799-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARDMS11532246XS1301X, 246XC2903X
ARDMS2471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular SpecialistGroup - Multi-Specialty
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS470000422OtherMEDICARE RAILROAD
MS00117333Medicaid
LA5CB82OtherMEDICARE OF LA
MS470000006Medicare ID - Type Unspecified