Basic Information
| Provider Information | |||||||||
| NPI: | 1366711673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRISTAN RADIOLOGY SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4520 UNION DEPOSIT RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171112910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176526105 | ||||||||
| FaxNumber: | 7176522165 | ||||||||
| Practice Location | |||||||||
| Address1: | 4518 UNION DEPOSIT RD | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171112921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176525840 | ||||||||
| FaxNumber: | 7176528152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2011 | ||||||||
| LastUpdateDate: | 03/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | DELOIA | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7176526105 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1026722000001 | 05 | PA | MEDICAID |