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NPI Code Detail

MEDICARE: CHICOT RADIOLOGY CONSULTANT

MEDICARE: CHICOT RADIOLOGY CONSULTANT
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
1174400000XSpecialistR2928

General Provider Information

NPI Number : 1437215878
Entity Type Code : Organization
Provider Name (Legal Business Name) : CHICOT RADIOLOGY CONSULTANT
Provider Business Mailing Address
First Line : 2729 S HIGHWAY 65 82
Second Line :
City : LAKE VILLAGE
State : AR
Zip : 71653-6136
Country : US
Telephone Number : 870-265-5074
Fax Number :
Provider Business Practice Location Address
First Line : 2729 S HIGHWAY 65 82
Second Line :
City : LAKE VILLAGE
State : AR
Zip : 71653-6136
Country : US
Telephone Number : 870-265-5074
Fax Number :
Authorized Official
Title or Position : RADIOLOGY
Name : DR. THEERASAK TUANGSITHTANON
Credential :
Telephone Number : 870-265-5074
Provider Enumeration Date : 12/29/2006
Last Update Date : 08/22/2020

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1871664425 — MICHAEL BRADLEY MAYFIELD MD PA
Practice Location Address:
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Directions to “CHICOT RADIOLOGY CONSULTANT ” Practice Location

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