Basic Information
| Provider Information | |||||||||
| NPI: | 1053311399 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST IMAGING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MINNEAPOLIS RADIOLOGY-ROBBINSDALE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2955 XENIUM LN N | ||||||||
| Address2: | SUITE 40 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | 7633988701 | ||||||||
| Practice Location | |||||||||
| Address1: | 3366 OAKDALE AVE N STE 401 | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635592171 | ||||||||
| FaxNumber: | 7633986601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | CARLSON | ||||||||
| AuthorizedOfficialFirstName: | KRISTEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7635592171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WEST IMAGING, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | 37855 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 37855 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1603353 | 01 | MEDICA | OTHER | 32543300 | 05 | MN | MEDICAID | 311L01MI | 01 | BCBS | OTHER | 325433000 | 05 | MN | MEDICAID |