Basic Information
| Provider Information | |||||||||
| NPI: | 1295835817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEMOGAS | ||||||||
| FirstName: | VYTAS | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1829 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838161829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086679334 | ||||||||
| FaxNumber: | 2086642341 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 N CECIL RD | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838546200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622805 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | M-5767 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | M5767 | 01 | ID | ID LICENSE | OTHER | VPS MEDICAL IMAGING | 01 | WA | COMPANY NAME | OTHER |