Provider Demographics
NPI:1124123963
Name:RADIOLOGY SERVICES OF ARDMORE, INC.
Entity type:Organization
Organization Name:RADIOLOGY SERVICES OF ARDMORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBRELL-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-452-9419
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0518
Mailing Address - Country:US
Mailing Address - Phone:479-452-9416
Mailing Address - Fax:479-484-0827
Practice Address - Street 1:1011 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:479-452-9416
Practice Address - Fax:479-484-0827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2085N0904X, 2085U0001X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100730410AMedicaid
OK100730410AMedicaid