Basic Information
| Provider Information | |||||||||
| NPI: | 1275081309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND IMAGING LLC - MT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 S STEVENS ST | ||||||||
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| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097474455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2419 MULLAN RD STE D | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097474455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2016 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5097474455 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INLAND IMAGING LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.