Provider Demographics
NPI:1487904173
Name:MID DELTA RADIOLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:MID DELTA RADIOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-832-3514
Mailing Address - Street 1:130 RIVER CLUB CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-9725
Mailing Address - Country:US
Mailing Address - Phone:662-832-3514
Mailing Address - Fax:866-782-0773
Practice Address - Street 1:130 RIVER CLUB CIR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-9725
Practice Address - Country:US
Practice Address - Phone:662-832-3514
Practice Address - Fax:866-782-0773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE77892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR209761002Medicaid