Basic Information
| Provider Information | |||||||||
| NPI: | 1326230939 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAOS MOUNTAIN RADIOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12687 W CEDAR DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802282010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034681395 | ||||||||
| FaxNumber: | 3034681394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1397 WEIMER RD | ||||||||
| Address2: | RADIOLOGY DEPARTMENT | ||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875716284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057588883 | ||||||||
| FaxNumber: | 5057517661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | EATON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5057588883 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD2002-0304 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.