Basic Information
| Provider Information | |||||||||
| NPI: | 1245295443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEDGECOCK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | DEPT 241 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741011559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772438418 | ||||||||
| FaxNumber: | 9186632281 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 RIFE MEDICAL LANE | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793388000 | ||||||||
| FaxNumber: | 5016640302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | C8265 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | C-8265 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 134366001 | 05 | AR | MEDICAID |