Basic Information
| Provider Information | |||||||||
| NPI: | 1255397832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEARTLAND IMAGING & INTERVENTIOANL RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 12/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | CLARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9186649892 | ||||||||
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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 | 200052410A | 05 | OK | MEDICAID |