Provider Demographics
NPI:1316059819
Name:PROFESSIONAL RADIOLOGY SERVICES, P.A.
Entity type:Organization
Organization Name:PROFESSIONAL RADIOLOGY SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:620-225-1033
Mailing Address - Street 1:2004 1ST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2697
Mailing Address - Country:US
Mailing Address - Phone:620-225-1033
Mailing Address - Fax:620-227-8491
Practice Address - Street 1:2004 1ST AVE STE A
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2697
Practice Address - Country:US
Practice Address - Phone:620-225-1033
Practice Address - Fax:620-227-8491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSCS8790OtherMEDICARE RAILROAD
COC395908Medicare PIN
KS004266Medicare ID - Type UnspecifiedPROVIDER NUMBER