Basic Information
| Provider Information | |||||||||
| NPI: | 1891786935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROSCAN IMAGING OF ARKANSAS, LLC | ||||||||
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| OtherOrganizationName: | PROSCAN IMAGING ARKANSAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9101 KANIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012277688 | ||||||||
| FaxNumber: | 5012283509 | ||||||||
| Practice Location | |||||||||
| Address1: | 9101 KANIS RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012247226 | ||||||||
| FaxNumber: | 5012251459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ALONZO | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5012277688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | M D | ||||||||
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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 | P00233253 | 01 | AR | RAILROAD MEDICARE | OTHER |