Basic Information
| Provider Information | |||||||||
| NPI: | 1003899584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY SERVICES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 5TH ST NE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584013300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012521050 | ||||||||
| FaxNumber: | 7019523265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | TAN | ||||||||
| AuthorizedOfficialFirstName: | RAYMUNDO | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | RADIOLOGIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7012521050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 12174 | 05 | ND | MEDICAID |