Basic Information
| Provider Information | |||||||||
| NPI: | 1730294950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL X-RAY SERVICES, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1908 | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028621908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017292836 | ||||||||
| FaxNumber: | 4017292721 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 BREWSTER ST | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017292836 | ||||||||
| FaxNumber: | 4017292721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | DESENA | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT PATIENT ACCOUNTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4017292836 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | HOS00128 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0009742557 | 05 | MA | MEDICAID | 0009000660 | 05 | RI | MEDICAID |