Basic Information
| Provider Information | |||||||||
| NPI: | 1134349319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALDWELL RADIOLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | 6608264852 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 W FERTITTA BLVD | ||||||||
| Address2: | |||||||||
| City: | LEESVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714464649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372395148 | ||||||||
| FaxNumber: | 3372395318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | CALDWELL | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3372395148 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1722669 | 05 | LA | MEDICAID | DE4858 | 01 | LA | RR MEDICARE | OTHER |