Basic Information
| Provider Information | |||||||||
| NPI: | 1750788865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSTAR RADIOLOGY - CALIFORNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2031 32ND ST S | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546017099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087888103 | ||||||||
| FaxNumber: | 6087888799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087888103 | ||||||||
| FaxNumber: | 6087888799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2014 | ||||||||
| LastUpdateDate: | 08/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | LECKIE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7758538422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 |
No ID Information.