Provider Demographics
NPI:1194121764
Name:PROFESSIONAL SONOGRAPHIC IMAGING
Entity type:Organization
Organization Name:PROFESSIONAL SONOGRAPHIC IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL SONOGRAPHER, RADIOGRAPHER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:TALWAR
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS RT
Authorized Official - Phone:731-676-7635
Mailing Address - Street 1:1505 WOODLAWN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3145
Mailing Address - Country:US
Mailing Address - Phone:731-676-7635
Mailing Address - Fax:731-334-5608
Practice Address - Street 1:1505 WOODLAWN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3145
Practice Address - Country:US
Practice Address - Phone:731-676-7635
Practice Address - Fax:731-334-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17398261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile