1134438955 NPI number — MADISON COUNTY IMAGING CENTER

Table of content: (NPI 1134438955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134438955 NPI number — MADISON COUNTY IMAGING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MADISON COUNTY IMAGING CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134438955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72766-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-927-3100
Provider Business Mailing Address Fax Number:
479-927-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 PHILLIPS PL
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72740-6266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-927-3100
Provider Business Practice Location Address Fax Number:
479-927-3131
Provider Enumeration Date:
09/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
479-927-3100

Provider Taxonomy Codes

  • Taxonomy code: 261QR0200X , with the licence number:  MC-2791 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5G469 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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