Basic Information
| Provider Information | |||||||||
| NPI: | 1053708297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA RIVER RADIOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 93 | ||||||||
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| City: | LANDISVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 175380093 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 E 19TH ST | ||||||||
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| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970583317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412961111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2015 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | BOYER | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8025580466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.