Basic Information
| Provider Information | |||||||||
| NPI: | 1194852715 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DE QUEEN MEDICAL CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705840272 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705840272 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | MATHESON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8705840272 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | AR4365 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5F418 | 01 | AR | BLUE CROSS | OTHER | 200064800A | 05 | OK | MEDICAID | 157501002 | 05 | AR | MEDICAID |