Basic Information
| Provider Information | |||||||||
| NPI: | 1306011473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC NORTHWEST RADIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26570 | ||||||||
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| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937296570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 602 CHASE AVENUE | ||||||||
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| City: | CORDOVA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995740160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074248000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOESSBERG | ||||||||
| AuthorizedOfficialFirstName: | BURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5416877134 | ||||||||
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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 | 7140551 | 05 | WA | MEDICAID | MDG34OR | 05 | OR | MEDICAID |