Provider Demographics
NPI:1659482529
Name:DIAGNOSTIC TISSUE/CYTOLOGY GROUP, PLLC
Entity type:Organization
Organization Name:DIAGNOSTIC TISSUE/CYTOLOGY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-553-6809
Mailing Address - Street 1:PO BOX 3780
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3780
Mailing Address - Country:US
Mailing Address - Phone:601-483-8300
Mailing Address - Fax:601-484-7776
Practice Address - Street 1:1512 20TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4124
Practice Address - Country:US
Practice Address - Phone:601-483-8300
Practice Address - Fax:601-484-7776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25D1011258291U00000X
MS25D0980061291U00000X
MS25D0318506291U00000X
MS25D0651894291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00132040OtherMEDICARE RAILROAD
MS07478777Medicaid
AL690000005Medicaid
MSF54742Medicare UPIN
MSP00132040OtherMEDICARE RAILROAD
C48282Medicare UPIN
MSE50693Medicare UPIN
AL690000005Medicaid
MSE71605Medicare UPIN
MSD80626Medicare UPIN