Basic Information
| Provider Information | |||||||||
| NPI: | 1427018324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST RADIOLOGY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720778 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055357669 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2825 PARKLAWN DR | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056108398 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 11/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | DEGNER | ||||||||
| AuthorizedOfficialFirstName: | ALFRED | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4055357669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 | 100735840A | 05 | OK | MEDICAID |