Basic Information
| Provider Information | |||||||||
| NPI: | 1578526919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAYETTEVILLE MRI LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799687930 | ||||||||
| FaxNumber: | 4799684331 | ||||||||
| Practice Location | |||||||||
| Address1: | 3873 N PARKVIEW DR | ||||||||
| Address2: | NO.6 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727036286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006540378 | ||||||||
| FaxNumber: | 4799684331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 02/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | COUCH | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4799687930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 149120002 | 05 | AR | MEDICAID | 5C735 | 01 | AR | BCBS PROVIDER NUMBER | OTHER |