Provider Demographics
NPI:1437215878
Name:CHICOT RADIOLOGY CONSULTANT
Entity Type:Organization
Organization Name:CHICOT RADIOLOGY CONSULTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:THEERASAK
Authorized Official - Middle Name:
Authorized Official - Last Name:TUANGSITHTANON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-265-5074
Mailing Address - Street 1:2729 S HIGHWAY 65 82
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-6136
Mailing Address - Country:US
Mailing Address - Phone:870-265-5074
Mailing Address - Fax:
Practice Address - Street 1:2729 S HIGHWAY 65 82
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-6136
Practice Address - Country:US
Practice Address - Phone:870-265-5074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R2928174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARB90629Medicare UPIN
AR57570Medicare ID - Type Unspecified