Provider Demographics
NPI:1861428351
Name:LAKELAND RADIOLOGISTS, PA
Entity type:Organization
Organization Name:LAKELAND RADIOLOGISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:EHRHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-982-7878
Mailing Address - Street 1:PO BOX 23073
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3073
Mailing Address - Country:US
Mailing Address - Phone:601-982-7878
Mailing Address - Fax:705-596-6704
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-982-7878
Practice Address - Fax:706-596-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011377Medicaid
MS09011377Medicaid