Provider Demographics
NPI:1659469344
Name:PROVIDENCE IMAGING CONSULTANTS, P.A.
Entity Type:Organization
Organization Name:PROVIDENCE IMAGING CONSULTANTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:KIRON
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-577-6702
Mailing Address - Street 1:PO BOX 2030
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-2030
Mailing Address - Country:US
Mailing Address - Phone:915-577-6702
Mailing Address - Fax:
Practice Address - Street 1:2001 N OREGON ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3320
Practice Address - Country:US
Practice Address - Phone:915-577-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112577501Medicaid
TX00A40WMedicare UPIN
TX00A40WMedicare PIN