Provider Demographics
NPI:1780651117
Name:RADIOLOGISTS PA
Entity Type:Organization
Organization Name:RADIOLOGISTS PA
Other - Org Name:PRIME MEDICAL IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:S
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-452-9416
Mailing Address - Street 1:PO BOX 3887
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3887
Mailing Address - Country:US
Mailing Address - Phone:479-452-9416
Mailing Address - Fax:479-484-0827
Practice Address - Street 1:5707 JENNY LIND RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-7435
Practice Address - Country:US
Practice Address - Phone:479-452-9416
Practice Address - Fax:479-484-0827
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIOLOGISTS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-03
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100726820AMedicaid
AR105694002Medicaid
OK100726820AMedicaid