Provider Demographics
NPI:1265651459
Name:OUTPATIENT RADIOLOGY CLINIC PA
Entity Type:Organization
Organization Name:OUTPATIENT RADIOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:870-735-5555
Mailing Address - Street 1:200 SOUTH ROHDES
Mailing Address - Street 2:STE B
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301
Mailing Address - Country:US
Mailing Address - Phone:870-735-5555
Mailing Address - Fax:870-735-5660
Practice Address - Street 1:200 SOUTH ROHDES
Practice Address - Street 2:STE B
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-735-5555
Practice Address - Fax:870-735-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC63042085R0202X
TNMD146622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D79412Medicare UPIN
AR51645Medicare ID - Type Unspecified