Healthcare Provider Details

I. General information

NPI: 1588845127
Provider Name (Legal Business Name): PCH RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N 14TH ST DEPT OF RADIOLOGY
PONCA CITY OK
74601-2035
US

IV. Provider business mailing address

200 HANNA DR
PONCA CITY OK
74604-5764
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-0575
  • Fax: 580-765-0584
Mailing address:
  • Phone: 321-698-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. RICHARD SCOTT ROSENBLUM
Title or Position: OWNER
Credential: DO
Phone: 321-698-3724