Basic Information
| Provider Information | |||||||||
| NPI: | 1033446802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BELLADONNA BREAST IMAGING CENTER PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 84064 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981248464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888465527 | ||||||||
| FaxNumber: | 6073247615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 116TH AVE NE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980043058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888465527 | ||||||||
| FaxNumber: | 6073247615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2009 | ||||||||
| LastUpdateDate: | 10/03/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ACHESON | ||||||||
| AuthorizedOfficialFirstName: | MARITA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8888465527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X | MD00021389 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 2085R0202X | MD00021389 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.