Basic Information
| Provider Information | |||||||||
| NPI: | 1548289531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGIC SERVICES OF OKLAHOMA PLLC | ||||||||
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| OtherOrganizationName: | CLINICAL RADIOLOGY OF OKLAHOMA STATEWIDE PLLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1907 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754031907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663025557 | ||||||||
| FaxNumber: | 9034532541 | ||||||||
| Practice Location | |||||||||
| Address1: | 1407 WHISENANT | ||||||||
| Address2: | |||||||||
| City: | DUNCAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802525300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | KIRBY | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4052864056 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200107470A | 05 | OK | MEDICAID |