Basic Information
| Provider Information | |||||||||
| NPI: | 1104018571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PANHANDLE RADIOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1030 | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739421030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803386515 | ||||||||
| FaxNumber: | 5802255423 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | GUYMON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 739424438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803386515 | ||||||||
| FaxNumber: | 5802255423 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5803386515 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 23914 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DG3161 | 01 | OK | RAILROAD MEDICARE | OTHER | 200118900A | 05 | OK | MEDICAID |