Basic Information
| Provider Information | |||||||||
| NPI: | 1184242521 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELEVATION MEDICAL IMAGING EVANSTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2393 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834032393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003385378 | ||||||||
| FaxNumber: | 2085238978 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 STATE HIGHWAY 150 S | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829305344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3074444215 | ||||||||
| FaxNumber: | 3074444219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | ANDRIKOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3074444215 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X | N | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.