Basic Information
| Provider Information | |||||||||
| NPI: | 1043338171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL IMAGING NORTH PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183123002 | ||||||||
| FaxNumber: | 2183123003 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 E BELTLINE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557464504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183123002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 11/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | COURNEYA | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2183123005 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 103198 | 01 | MN | UCARE | OTHER | 782012700 | 05 | MN | MEDICAID | CD6182 | 01 | MN | RAILROAD MEDICARE | OTHER | 69531ME | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER |