Basic Information
| Provider Information | |||||||||
| NPI: | 1124056734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY CONSULTANTS A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70378 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997070378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074562784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1650 COWLES ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074585660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | ALLAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9074562784 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | GR0138 | 05 | AK | MEDICAID |