Basic Information
| Provider Information | |||||||||
| NPI: | 1487730594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSULTING RADIOLOGISTS, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Practice Location | |||||||||
| Address1: | 7595 ANAGRAM DR | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553447399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | ENGMARK | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6125732200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 322 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 322 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 322 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 322 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0204X | 322 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | 322 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 322 | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 03083CO | 01 | MN | BC/BS | OTHER | 587708300 | 05 | MN | MEDICAID | 32702700 | 05 | WI | MEDICAID | CC7547 | 01 | MN | RR MEDICARE | OTHER | 0984658 | 05 | IA | MEDICAID | CG5296 | 01 | WI | RR MEDICARE | OTHER |