Basic Information
| Provider Information | |||||||||
| NPI: | 1861464034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE RADIOLOGY GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25184 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972980184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032929108 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 9205 SW BARNES RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032164830 | ||||||||
| FaxNumber: | 5032164850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | PUTNAM | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5032929108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 029264 | 05 | OR | MEDICAID | DE8225 | 01 | OR | RAILROAD MEDICARE PIN | OTHER | R139758 | 01 | OR | MDCR PTAN | OTHER |