1417600412 NPI number — BREAST IMAGING OF THE OZARKS LLC

Table of content: AMMAR WEHBEH MD (NPI 1669461455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417600412 NPI number — BREAST IMAGING OF THE OZARKS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREAST IMAGING OF THE OZARKS LLC
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:
1417600412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3206 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75605-5143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-663-4800
Provider Business Mailing Address Fax Number:
903-663-9960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2144 E REPUBLIC RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-945-9455
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LACKEY
Authorized Official First Name:
LOGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
870-945-9455

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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