Basic Information
| Provider Information | |||||||||
| NPI: | 1558591578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTROSE RADIOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1301 | ||||||||
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| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814021301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707650818 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814014212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702492211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2009 | ||||||||
| LastUpdateDate: | 06/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | RAZIANO | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9705962441 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 44856 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 55526349 | 05 | CO | MEDICAID |