Provider Demographics
NPI:1093771321
Name:PROVIDENCE RADIOLOGY
Entity Type:Organization
Organization Name:PROVIDENCE RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-728-6145
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 919
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-728-6145
Mailing Address - Fax:
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:STE 919
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-728-6145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG4619OtherRR MEDICARE