Basic Information
| Provider Information | |||||||||
| NPI: | 1356560908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC NORTHWEST RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26570 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937296570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34 LAVALLE CT | ||||||||
| Address2: | |||||||||
| City: | UNALASKA | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996851202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075811202 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | LOESSBERG | ||||||||
| AuthorizedOfficialFirstName: | BURT | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5416877134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 314344 | AK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | MDG34OR | 05 | OR | MEDICAID |