1487705760 NPI number — RAD-ONE, PA

Table of content: (NPI 1487705760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487705760 NPI number — RAD-ONE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAD-ONE, PA
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:
6
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:
1487705760
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
618 FREDERICK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38732-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-435-5044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7420 GUTHRIE DR N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-5876
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-349-4321
Provider Business Practice Location Address Fax Number:
662-996-1533
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
YVETTE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL BILLING COORDINATOR
Authorized Official Telephone Number:
716-435-5044

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)

  • Identifier: 09015498 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5F243 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: DD5320 . This is a "MS RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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