Basic Information
| Provider Information | |||||||||
| NPI: | 1063470201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAUI DIAGNOSTIC IMAGING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1300 | ||||||||
| Address2: | MAIL CODE 61059 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968071300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256354411 | ||||||||
| FaxNumber: | 4256374646 | ||||||||
| Practice Location | |||||||||
| Address1: | 53 PUUNENE AVE | ||||||||
| Address2: | STE 115 | ||||||||
| City: | KAHULUI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088776402 | ||||||||
| FaxNumber: | 8088715587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | HALLIDAY | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER OF OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4256373378 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 0200997 | 01 | WA | DEPT OF L & I | OTHER |