Provider Demographics
NPI:1528166725
Name:RADIOLOGY CLINIC
Entity type:Organization
Organization Name:RADIOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:662-328-8404
Mailing Address - Street 1:2400 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2000
Mailing Address - Country:US
Mailing Address - Phone:662-328-8404
Mailing Address - Fax:662-329-4645
Practice Address - Street 1:2400 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2000
Practice Address - Country:US
Practice Address - Phone:662-328-8404
Practice Address - Fax:662-329-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS049082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS411589514OtherBLUE CROSS OF MS
MS09010990Medicaid
MSB30595Medicare UPIN
MS411589514OtherBLUE CROSS OF MS