Basic Information
| Provider Information | |||||||||
| NPI: | 1295015055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROCKDALE BLACKHAWK LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RICHARDS MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1010 | ||||||||
| Address2: | |||||||||
| City: | ROCKDALE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765671010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124464500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3101 HIGHWAY 71 E | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BASTROP | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786025156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123320222 | ||||||||
| FaxNumber: | 5123320229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 09/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | MADISON | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5124464500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.