Basic Information
| Provider Information | |||||||||
| NPI: | 1861972721 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MDIG OF PENNSYLVANIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10835 N 25TH AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850293458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022462584 | ||||||||
| FaxNumber: | 6022462566 | ||||||||
| Practice Location | |||||||||
| Address1: | 10835 N 25TH AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022462584 | ||||||||
| FaxNumber: | 6022462566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2018 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | PRINCE | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCM OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4809991091 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | PROCESSING | 05 | PA | MEDICAID |