Basic Information
| Provider Information | |||||||||
| NPI: | 1922006519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED DIAGNOSTIC RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2537 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588022537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663386472 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 15TH AVE W | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 588013821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017747401 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 10/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | MORADIAN | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2085570999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | IF - 8L493 | 01 | ID | BC NUMBER - IDAHO FALLS | OTHER | POC - 8L501 | 01 | ID | BC NUMBER FOR POCATELLO | OTHER | 807083700 | 05 | ID | MEDICAID | 8M916 | 01 | UT | BC OF IDAHO | OTHER | 000010149528 | 01 | ID | BLUE SHIELD NUMBER | OTHER | 15040 | 05 | ND | MEDICAID |