Email for non-humans

General Information

General Information Previous Next

Radiology Center Name *

Trade Name

License Number *

Registration Date

Ownership Type *

Sole ProprietorshipPartnershipCorporationOther

Other Ownership Type

Type of Facility *

• Diagnostic Imaging Center
• Hospital-based Radiology Unit
• Specialized Radiology Center
• Other

Other Facility Type

Contact Details

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Registered Address *

Country

Saudi ArabiaUnited Arab EmiratesQatarKuwaitOmanBahrainLebanon

City

Postal Code

Telephone

Mobile

Email *

Website

Primary Contact Person *

Position / Title

Direct Phone

Primary Contact Email

Licensing

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Operating License Issued By *

License Expiry Date

Commercial Registration Number

Tax Registration Number

Accreditation Status

AccreditedNot AccreditedIn Process

Accrediting Body

Accreditation Expiry Date

Management

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Medical Director Name *

Specialty

Medical Director License Number

Administrative Manager Name

Finance / Billing Contact

Claims Contact

Services Offered

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Diagnostic Imaging Services

• X-Ray
• Ultrasound
• Mammography
• CT Scan
• MRI
• Fluoroscopy
• Bone Densitometry (DEXA)
• Interventional Radiology
• Nuclear Medicine
• Doppler Studies
• Dental Radiology
• Other

Other Diagnostic Imaging Service

Reporting Services

• On-site Radiologist Reporting
• Teleradiology
• Second Opinion Reporting
• Urgent / STAT Reporting

Operating Hours

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24-Hour Service Available

YesNo

Regular Working Days

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday

Opening Hour

Closing Hour

Gallery

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Gallery

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Documents

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Valid Operating License

File name:

File size:

Commercial Registration Certificate

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Tax Registration Certificate

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Medical Director License

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File size:

Radiologists’ Licenses

File name:

File size:

Accreditation Certificate

File name:

File size:

Tariff / Price List

File name:

File size:

Bank Details / Payment Information

File name:

File size:

Professional Liability Insurance

File name:

File size:

Sample Reports

File name:

File size:

Other Document

File name:

File size:

Bank Details

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Bank Name

Account Name

Account Number / IBAN

SWIFT Code

Branch

Declaration

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Declaration

We hereby certify that the information provided in this form is true, complete, and accurate…

Authorized Signatory Name *

Title *

Signature

Date *

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