Basic Information
| Provider Information | |||||||||
| NPI: | 1922164482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN OREGON RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18858 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895110188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752833315 | ||||||||
| FaxNumber: | 7756249763 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419638421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | KIRKHAM | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5419638421 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/26/2020 | ||||||||
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 | 041077000 | 01 | OR | REGENCE | OTHER | CJ6070 | 01 | OR | RAILROAD MEDICARE | OTHER | 194663800 | 01 | OR | DEPT LABOR | OTHER | 226258 | 05 | OR | MEDICAID |