Provider Demographics
NPI:1053307108
Name:SAMA INDEPENDENT DIAGNOSTIC TESTING FACILITY
Entity Type:Organization
Organization Name:SAMA INDEPENDENT DIAGNOSTIC TESTING FACILITY
Other - Org Name:SAMA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-864-8120
Mailing Address - Street 1:600 S TIMBERLANE DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-6990
Mailing Address - Country:US
Mailing Address - Phone:870-862-2400
Mailing Address - Fax:870-862-1891
Practice Address - Street 1:600 S TIMBERLANE DR
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6990
Practice Address - Country:US
Practice Address - Phone:870-862-2400
Practice Address - Fax:870-862-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR223250261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C470Medicare ID - Type Unspecified