Basic Information
| Provider Information | |||||||||
| NPI: | 1154301786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY SERVICES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1983 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729021983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794529416 | ||||||||
| FaxNumber: | 4792421990 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 TOWSON AVE | ||||||||
| Address2: | |||||||||
| City: | FT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183922877 | ||||||||
| FaxNumber: | 9186632281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4794529416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MC0013 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100726770A | 05 | OK | MEDICAID | 105697002 | 05 | AR | MEDICAID |