Provider Demographics
NPI:1699744326
Name:RADIOLOGISTS OF RUSSELLVILLE PA
Entity type:Organization
Organization Name:RADIOLOGISTS OF RUSSELLVILLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-968-7930
Mailing Address - Street 1:P.O. BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811
Mailing Address - Country:US
Mailing Address - Phone:479-968-7930
Mailing Address - Fax:479-968-4331
Practice Address - Street 1:3301 W MAIN PL
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2334
Practice Address - Country:US
Practice Address - Phone:479-968-7930
Practice Address - Fax:479-968-1673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56763OtherARKANSAS BCBS
AR103880002Medicaid
AR56763OtherARKANSAS BCBS