Healthcare Provider Details

I. General information

NPI: 1023063260
Provider Name (Legal Business Name): ENID RADIOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S 5TH ST
ENID OK
73701-5832
US

IV. Provider business mailing address

PO BOX 1847
ENID OK
73702-1847
US

V. Phone/Fax

Practice location:
  • Phone: 580-234-2878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILIP MALONE
Title or Position: ADMINISTRATIVE MANAGER
Credential:
Phone: 405-321-8125