Healthcare Provider Details

I. General information

NPI: 1760660351
Provider Name (Legal Business Name): MED IMAGING OF ARKANSAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6948 ALCOA RD SUITE G
BENTON AR
72015-9726
US

IV. Provider business mailing address

6948 ALCOA RD SUITE G
BENTON AR
72015-9726
US

V. Phone/Fax

Practice location:
  • Phone: 501-778-9729
  • Fax: 501-776-2695
Mailing address:
  • Phone: 501-778-9729
  • Fax: 501-776-2695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. BONNIE J. ROAN
Title or Position: ADMINISTRATION MANAGER
Credential:
Phone: 501-778-9729