Basic Information
| Provider Information | |||||||||
| NPI: | 1336323047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST RADIOLOGISTS INC., P.S. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MT. BAKER PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4029 NORTHWEST AVE | ||||||||
| Address2: | SUITE 301A | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982269077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607330430 | ||||||||
| FaxNumber: | 3605944012 | ||||||||
| Practice Location | |||||||||
| Address1: | 4029 NORTHWEST AVE | ||||||||
| Address2: | SUITE 301A | ||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982269077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607330430 | ||||||||
| FaxNumber: | 3607330438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLAR | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 3607889004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHWEST RADIOLOGISTS INC PS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8904202 | 01 | WA | CRIME VICTIMS PROVIDER # | OTHER | 0185434 | 01 | WA | DLI PROVIDER # | OTHER | 7122831 | 05 | WA | MEDICAID |