1780651117 NPI number — RADIOLOGISTS PA

Table of content: (NPI 1780651117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780651117 NPI number — RADIOLOGISTS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIOLOGISTS 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:
PRIME MEDICAL IMAGING
Provider Other Organization Name Type Code:
3
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:
1780651117
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3887
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72913-3887
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-452-9416
Provider Business Mailing Address Fax Number:
479-484-0827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5707 JENNY LIND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72908-7435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-452-9416
Provider Business Practice Location Address Fax Number:
479-484-0827
Provider Enumeration Date:
03/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DANIELS
Authorized Official First Name:
GREGG
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
479-452-9416

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: 100726820A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105694002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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