MEDICARE: ST.BERNARDS IMAGING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1376506980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST.BERNARDS IMAGING CENTER

Provider Business Mailing Address
First Line	:	PO BOX 9178
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72811-9178
Country	:	US
Telephone Number	:	479-968-7930
Fax Number	:	479-968-4331

Provider Business Practice Location Address
First Line	:	1144 E MATTHEWS AVE
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72401-4314
Country	:	US
Telephone Number	:	800-803-6376
Fax Number	:	479-968-4331

Authorized Official
Title or Position	:	MANAGER
Name	:	KERRI COUCH
Credential	:
Telephone Number	:	479-968-7930

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	08/22/2020

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