Basic Information
| Provider Information | |||||||||
| NPI: | 1699956391 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADIOLOGICAL ASSOCIATES OF DULUTH | ||||||||
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| OtherOrganizationName: | HIBBING IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 E 37TH ST | ||||||||
| Address2: | SUITE 30 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183121200 | ||||||||
| FaxNumber: | 2183121201 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E 37TH ST | ||||||||
| Address2: | SUITE 30 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183121200 | ||||||||
| FaxNumber: | 2183121201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2007 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | SUSLAVICH | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2187223700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADIOLOGICAL ASSOCIATES OF DULUTH | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 695210100 | 05 | MN | MEDICAID |