Basic Information
| Provider Information | |||||||||
| NPI: | 1043456643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL IMAGING GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9400 SW BARNES RD | ||||||||
| Address2: | SUITE 307 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037976356 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 18040 SW LOWER BOONES FERRY ROAD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032168440 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2009 | ||||||||
| LastUpdateDate: | 01/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | PUTNAM | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 5032164830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | PENDING | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.