Basic Information
Provider Information | |||||||||
NPI: | 1972729762 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PACIFIC NORTHWEST RADIOLOGY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26570 | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937296570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416877134 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 209 MOLLER AVE | ||||||||
Address2: |   | ||||||||
City: | SITKA | ||||||||
State: | AK | ||||||||
PostalCode: | 998357142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077473241 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOESSBERG | ||||||||
AuthorizedOfficialFirstName: | BURT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 5416877134 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 314344 | AK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | MDG34OR | 05 | OR |   | MEDICAID |