Provider Demographics
NPI:1265475230
Name:FOUR CORNERS RADIOLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:FOUR CORNERS RADIOLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-325-1572
Mailing Address - Street 1:PO BOX 2019
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-2019
Mailing Address - Country:US
Mailing Address - Phone:505-325-1572
Mailing Address - Fax:505-327-4887
Practice Address - Street 1:801 W. MAPLE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-1572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44016Medicaid
NM44016Medicaid