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General NPI Number Information
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NPI Number | 1548599988
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Entity Type | Organization
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Legal Business Name | INTERVENTIONAL AND DIAGNOSTIC RADIOLOGY OF SOUTH ARKANSAS, P.A.
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Dates
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Enumeration Date | 12/14/2009
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Last Update Date | 12/14/2009
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Provider Practice Location Address
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Address Line | 700 W GROVE ST
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City | EL DORADO
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State | AR
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Zip | 71730-4416
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Country | US
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Telephone | 870-862-1577
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Fax | 870-862-5916
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Provider Business Mailing Address
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Address Line | 611 THOMPSON AVE
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City | EL DORADO
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State | AR
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Zip | 71730-4557
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Country | US
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Telephone | 870-862-1577
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Fax | 870-862-5916
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MRS. BRENDA WILSON
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Credential |
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Telephone | 870-862-1577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | C5187
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License Number State | AR
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