Basic Information
| Provider Information | |||||||||
| NPI: | 1538167788 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL X-RAY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 160 | ||||||||
| Address2: | |||||||||
| City: | GRAVEVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 15634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245276517 | ||||||||
| FaxNumber: | 7245276519 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | JEANNETTE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156442505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245273551 | ||||||||
| FaxNumber: | 7245276519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ANNAMARJU | ||||||||
| AuthorizedOfficialFirstName: | SRINIVAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | RADIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7245273551 | ||||||||
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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 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | CF7023 | 01 | RRMED | OTHER | 0009210190010 | 05 | PA | MEDICAID |