Basic Information
| Provider Information | |||||||||
| NPI: | 1922253525 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGEPORT MEDICAL IMAGING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTER FOR MEDICAL IMAGING-BRIDGEPORT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25809 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972980809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037976356 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Practice Location | |||||||||
| Address1: | 18040 SW LOWER BOONES FERRY ROAD | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032168440 | ||||||||
| FaxNumber: | 5032920346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAZARD | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5032164830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 |
No ID Information.