Basic Information
| Provider Information | |||||||||
| NPI: | 1902849276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARKANSAS DIAGNOSTIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8908 KANIS RD | ||||||||
| Address2: | P.O. BOX 55130 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012277688 | ||||||||
| FaxNumber: | 5012252930 | ||||||||
| Practice Location | |||||||||
| Address1: | 8907 KANIS RD | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012179382 | ||||||||
| FaxNumber: | 5012252930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | YORK | ||||||||
| AuthorizedOfficialFirstName: | MARION | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5012277688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2557 | AR | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100013053 | 01 | AR | RAILROAD DR ZILLER | OTHER | 117730002 | 05 | AR | MEDICAID | CC6622 | 01 | AR | RAILORAD MEDICARE | OTHER | 010009296 | 01 | AR | RAILROAD DR WMS | OTHER |