Basic Information
| Provider Information | |||||||||
| NPI: | 1376628263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSTAR IMAGING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32936 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779056553 | ||||||||
| FaxNumber: | 6087888799 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 E HASKELL ST | ||||||||
| Address2: | |||||||||
| City: | WINNEMUCCA | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894453247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756235222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | LECKIE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7758138054 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 300075919 | 01 | NV | RAILROAD MEDICARE | OTHER | DB5649 | 01 | UT | RAILROAD MEDICARE | OTHER | 100500055 | 05 | NV | MEDICAID |