Healthcare Provider Details

I. General information

NPI: 1124123963
Provider Name (Legal Business Name): RADIOLOGY SERVICES OF ARDMORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/17/2020
Certification Date: 07/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

IV. Provider business mailing address

PO BOX 518
ARDMORE OK
73402-0518
US

V. Phone/Fax

Practice location:
  • Phone: 479-452-9416
  • Fax: 479-484-0827
Mailing address:
  • Phone: 479-452-9416
  • Fax: 479-484-0827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateOK

VIII. Authorized Official

Name: MRS. JULIE DIBRELL-GARCIA
Title or Position: MANAGER
Credential:
Phone: 479-452-9419