Provider Demographics
NPI:1679775001
Name:MOLECULAR IMAGING ASSOC PLLC
Entity type:Organization
Organization Name:MOLECULAR IMAGING ASSOC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-334-9829
Mailing Address - Street 1:136 FIORANELLI DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7313
Mailing Address - Country:US
Mailing Address - Phone:662-334-9829
Mailing Address - Fax:662-334-3529
Practice Address - Street 1:136 FIORANELLI DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7313
Practice Address - Country:US
Practice Address - Phone:662-334-9829
Practice Address - Fax:662-334-3529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS105892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS587403483OtherBLUE CROSS OF MS
MS09016013Medicaid
MS300132286OtherRAILROAD MEDICARE
MS587403483OtherBLUE CROSS OF MS