Basic Information
| Provider Information | |||||||||
| NPI: | 1629109111 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGY ASSOCIATES OF DURANGO PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 394 | ||||||||
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| City: | GRETNA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680280394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774062976 | ||||||||
| FaxNumber: | 7195912745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 THREE SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813018296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707642286 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALTERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9702592525 | ||||||||
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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 | 2085N0904X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | E2677 | 05 | NM | MEDICAID | X9X000484 | 05 | TX | MEDICAID | 209463 | 01 | US DEPARTMENT OF LABOR | OTHER | 04005427 | 05 | CO | MEDICAID | 825698 | 05 | AZ | MEDICAID | 10025313600 | 05 | CA | MEDICAID | RAB6508 | 01 | CO | BLUE CROSS BLUE SHIELD | OTHER |