Basic Information
| Provider Information | |||||||||
| NPI: | 1376536763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YELLOWSTONE RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1829 | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838161829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006679334 | ||||||||
| FaxNumber: | 2086642341 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 SHERIDAN AVE | ||||||||
| Address2: | |||||||||
| City: | CODY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824143409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086679334 | ||||||||
| FaxNumber: | 2086642341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3075782582 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | DC9336 | 01 | WY | RR MEDICARE | OTHER | 120635400 | 05 | WY | MEDICAID |