Basic Information
Provider Information | |||||||||
NPI: | 1457417065 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDICAL ARTS DIAGNOSTIC CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDICAL ARTS DIAGNOSTIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 175 SOUTH RANGE | ||||||||
Address2: | SUITE 2 | ||||||||
City: | COLBY | ||||||||
State: | KS | ||||||||
PostalCode: | 677010001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7854623332 | ||||||||
FaxNumber: | 7854623337 | ||||||||
Practice Location | |||||||||
Address1: | 175 SOUTH RANGE | ||||||||
Address2: | SUITE 2 | ||||||||
City: | COLBY | ||||||||
State: | KS | ||||||||
PostalCode: | 677010001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7854623332 | ||||||||
FaxNumber: | 7854623337 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2006 | ||||||||
LastUpdateDate: | 07/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HILDYARD | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7854623332 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEDICAL ARTS DIAGNOSTIC CENTER, LLC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247100000X |   | KS | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |   | 247100000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist |   |
ID Information
ID | Type | State | Issuer | Description | 100643310B | 05 | KS |   | MEDICAID |