Provider Demographics
NPI:1770705915
Name:FIDELIS RADIOLOGY, INC.
Entity type:Organization
Organization Name:FIDELIS RADIOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-392-0720
Mailing Address - Street 1:P.O. BOX 702586
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170
Mailing Address - Country:US
Mailing Address - Phone:918-392-0720
Mailing Address - Fax:
Practice Address - Street 1:7718 E 91ST ST
Practice Address - Street 2:SUITE 220
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6045
Practice Address - Country:US
Practice Address - Phone:918-392-0720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739530AMedicaid
OKDE8794OtherRAILROAD MEDICARE
OK100739530AMedicaid
OKDE8794OtherRAILROAD MEDICARE